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Aligning practice with policy to improve

patient care

Volume 3, Issue 2

Back to Basics: Electrosurgery

How to Thrive in a Tough Economy

Surgical Site Infections: Are you playing your part in prevention? FREE CE PAGE 22


Pressure Ulcer Factors to Keep in Mind

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We also welcome any suggestions you might have on how we can continue to improve The OR Connection! Love the content? Want to see something new? Just let us know! About Medline Medline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals, extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than 700 dedicated sales representatives nationwide to support its broad product line and cost management services. 漏 2008 Medline Industries, Inc. The OR Connection is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 60060. 1-800-MEDLINE.

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OR Connection Aligning practice with policy to improve

Editor Sue MacInnes, RD, LD Clinical Editor Alecia Cooper, RN, BS, MBA, CNOR Contributing Editor Andy J. Mills, MBA, MWM Art Director Mike Gotti Copy Editor Laura Kuhn Clinical Team Jayne Barkman, RN, BSN, CNOR Rhonda J. Frick, RN, CNOR Anita Gill, RN

Megan Giovinco, RN, CNOR, RNFA

Kimberly Haines, RN, Certified OR Nurse Jeanne Jones, RNFA, LNC Carla Nitz, RN, BSN

Connie Sackett, RN, Nurse Consultant Claudia Sanders, RN, CFA

Angel Trichak, RN, BSN, CNOR

Perioperative Advisory Board Gail Avigne, RN Shands Teaching Hospital (UFL), Florida

Caroline Copeland, RN MPH Southern Hills Hospital & Medical Center

Cathy Crandall, RN HealthTrust Purchasing Organization, Tennessee Larry Creech, RN, MBA, CDT Carilion Health System, Virginia

Pat DʼErrico, RN, CNOR Medical Center of Central Georgia, Georgia Barbara Fahey, RN CNOR Cleveland Clinic, Ohio

Zaida Jacoby, RN, MA, M.Ed NYU Medical Center, New York

Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA Wellstar Kennestone Hospital, Georgia Wayne Malone, RN Physicians Hospital, Texas

Lynda Mansfield, RN, CNOR Orange County Memorial, California Jackie Minor, RN CNOR Huntsville Hospital, Alabama

Jennifer Misajet, BSN, MHA, CNOR Exempla St. Joseph Hospital, Colorado

Pricilla Ranseur, RN, MSN, CNOR Duke University Hospital, North Carolina

Margie Voyles, RN, MS, CNOR Lakeland Regional Medical Center, Florida

patient care


16 Back to Basics: Electrocautery Safety and OR Fire Prevention 24 Left Behind 30 World Health Organization Issues Safety Checklist for Surgical Teams 37 Surgical Site Infections 43 Flipping the Switch on Pressure 46 Five Pressure Ulcer Factors to Keep in Mind

Page 13


40 Great Ideas from Your Peers: Surgical Skin Prep Solutions 50 The History of the Surgical Technologist SPECIAL FEATURES

5 13 32 54 58 62 68 71 73

Letters from Our Readers SCIP’s Role in the CMS 9th Scope of Work Proposal Moments of Truth A Place of Healing? Callie Craig: A Nurse Hero How to Thrive in a Tough Economy Angel’s Passion for Pink Medline Supports Breast Cancer Awareness Recipe: Guacamole

Page 16

Page 24


61 Building Unshakable Self-Confidence 72 Ease the Discomfort of PMS FORMS & TOOLS

76 78 81 86 89

Electrosurgery Checklist Electrosurgical Cautery Safety Pressure Ulcer Prevention Surgical Safety Checklist Checklist: Organizational Assessment Questions Regarding Management Commitment to Employee Involvement 90 Confidential Incident Report

Page 32

Page 62

Margery Woll, RN, MSN, CNOR Rush North Shore, Illinois

Aligning practice with policy to improve patient care 3

THE OR CONNECTION I Letter from the Editor Dear Reader,

Everyone agrees that preventing hospitalacquired conditions can save thousands of lives and millions of dollars. This is the time to take action. Hospitals across the country are implementing new strategies. All of us are feeling the swell of change and the push back that comes with it. Whether you are working with administration, materials management, your staff, physicians, vendors, consultants or your peers, the journey isnʼt and wonʼt be easy. Iʼve spoken to thousands of clinicians about the barriers they are facing when it comes to implementing new policies and improving safety, quality and patient satisfaction. Everyone wants to do whatʼs right. The overwhelming things that we need to make that happen are teamwork, communication, education and – in many cases – additional resources.

This edition of The OR Connection is about bringing positive change into your facility. One key solution that can help your patients receive a higher standard of care is the use of a checklist. I know if something is not on my list, there is a chance it will be forgotten. With the day-to-day pressure, interruptions and stress that each of you must deal with in the OR, a checklist might be just the right calming factor. Checklists act as reminders to keep us on track, to make sure weʼve covered everything we need to do. Youʼll want to take a look at Page 30, where you will find the “Safety Checklist for Surgical Teams.” There are three recommended checklists:

Then go to Page 86 in the Forms & Tools section, where you can tear out a copy of the checklists for your own use.

But even with your checklist in hand, it might not be enough. That is why you should read through “Moments of Truth: How to enact a culture change at your facility.” There are no miracles here, but a keen understanding and expert guidance on how to create a team that works together, problem-solves together, helps each other out to give the patient the best care possible. Each of us contributes to the culture we work in, so I was thrilled with Wolfe Rinkeʼs article “How to Thrive in A Tough Economy” (Page 62). This article takes a closer look at how you can positively affect your organization and your career in these times. Last, but certainly not least, this edition is chock-full of safety updates and information. Thank you for being a part of the team. We look forward to visiting with you again in our next edition. Sincerely,

Sue MacInnes, RD, LD Editor

1. Before anesthesia is induced 2. Before skin incision 3. Before the patient leaves the operating room

We've coded the articles and information in this magazine to indicate which patient care initiatives they pertain to. Throughout the publication, when you see these icons you'll know immediately that the subject matter on that page relates to one or more of the following national initiatives: • IHI's 5 Million Lives Campaign • Joint Commission 2007 National Patient Safety Goals • Surgical Care Improvement Project (SCIP)

Content Key

We've tried to include content that clarifies the initiatives or gives you ideas and tools for implementing their recommendations. For a summary of each of the above initiatives, see pages 6 and 7.


The OR Connection

This edition of The OR Connection is about bringing positive change into your facility.”

You Said It!

Letters from Our Readers

I really enjoy The OR Connection and find the articles to be interesting, current and evidence-based. I look forward to the new issues and have been able to implement some of the tools as teaching aids. Thank you very much for a publication specifically for the OR which puts policy and practice together to improve patient care and safety. – Maureen Bollin, RN, CNOR, Perioperative Educator

As an educator, I was pleased with the timeliness of the articles, the activities for the staff and their presentation. The topics are pertinent, and easy to read. I love the variety to articles. I am only sorry I don't have all your issues. This magazine is a great resource tool, and when your staff needs an in-service, there is always something to draw on. Thank you for publishing it, I hope it continues. – K. Smith

This type of project is so very valuable to clinicians and establishes your clinical credibility that is a major differentiator in the market today. Kudos to you and to your clinical team. – Sandy Wise, RN, MBA

I received this issue at AORN Congress this year in Orlando. What a GREAT magazine this is!!! It incorporates so many of today's issues affecting perioperative care. The education is invaluable. Thank you! – Rose Trojkovich

I recently got to read Volume 2, Issue 1 given to me by a fellow OR nurse and I really enjoyed the great reading and love the format. I plan on using this info in education of the OR staff in my facility. As an educator I am always looking for

fresh ideas and articles to share with my staff that is relevant and easy to understand. I just signed up for a subscription for our OR dept and want to thank you. I think the crosswords and word search are fun and informative. – Sara Smith, RN, CNOR

I wanted to pass along a thank you for The OR Connection magazine you dropped off. I really enjoy reading them. There is a lot of valuable information in it that I pass along to others. I get a lot of magazines in the mail and I must say this is one of the few I review cover to cover and pass on to others. Medline does a nice job with this. Thanks again! – Janna Petersen, RN

I love your magazine, keep up the good work! – Lynne Arnaut

The Back to Basics series has become a hit at our two facilities….I had been working hard on getting staff to read your great issues of The OR Connection and now it looks like it has finally happened. – Sophia Schild

Great issue of The OR Connection! I am just amazed at the content, information, format, etc. You do have a gift for this publication series. – Nancy B. Bjerke, RN, MPH, CIC

Has The OR Connection been helpful at your facility? Is there a topic youʼd love to see us tackle? Drop us a line at Weʼd love to hear from you!

Aligning practice with policy to improve patient care 5

Three Important National Initiatives for Improving Patient Care Achieving better outcomes starts with an understanding of current patient-care initiatives. Here’s what you need to know about national projects and policies that are driving changes in care.


5 Million Lives Campaign

Origin: Purpose: Goal:

Launched by the Institute for Healthcare Improvement (IHI) in December of 2006 To prevent unintended physical injury resulting from or contributed to by medical care that requires additional monitoring, treatment or hospitalization, or that results in death To prevent five million incidents of medical harm over the next two years and to enroll more than 4,000 hospitals and their communities in the project.

Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides and tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.

The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.


Origin: Purpose:

Joint Commission 2008 National Patient Safety Goals Developed by Joint Commission staff and a Sentinel Event Advisory Group To promote specific improvements in patient safety, particularly in problematic areas

Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission offers guidance to help organizations meet goal requirements. This yearʼs new requirements have a one-year phase-in period that includes defined expectations for planning, development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation by January 2009.


Origin: Purpose: Goal:

Surgical Care Improvement Project (SCIP) Initiated in 2003 as a national partnership. Steering committee includes the following organizations: CDC, CMS, ACS, AHRQ, AHA, ASA, AORN, VA, IHI and the Joint Commission To improve patient safety by reducing postoperative complications To reduce nationally by 25 percent the incidence of surgical complications by 2010

SCIP aims to reduce surgical complications in four target areas. Participating hospitals collect data on specific process and outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical complications annually (just in Medicare patients) by getting performance up to benchmark levels.


The OR Connection

Patient Safety

5 Million Lives Campaign: Twelve Interventions 1. Prevent pressure ulcers 2. Reduce methicillin-resistant staphylococcus aureus (MRSA) infection 3. Prevent harm from high-alert medications 4. Reduce surgical complications 5. Deliver evidence-based care for congestive heart failure 6. Get boards on board 7. Deploy rapid response teams 8. Prevent adverse drug events (ADEs)


9. Deliver evidence–based care for acute myocardial infarction 10.Prevent surgical-site infections 11. Prevent central-line infections 12.Prevent ventilator-associated pneumonia

By the numbers: • 3,954 hospitals currently enrolled • The Top 3 Interventions: 1. Adverse Drug Events (ADEs) – 3,010 • An IHI forum, “Celebrating 20 Years: The Future 2. Surgical Site Infection (SSI) – 2,923 of Health Care is Ours to Imagine,” will be held in 3. Acute Myocardial Infarction (AMI) – 2,893 Nashville December 8-11, 2008 • For the latest on patient safety, visit To learn more, visit

Joint Commission 2008 National Patient Safety Goals

• Improve accuracy of patient identification • Improve effectiveness of communication among caregivers Improve medication safety Reduce risk of healthcare-associated infections (Expanded in 2008 to include either WHO or CDC Hand Hygiene Guidelines) Reduce risk of patient harm from falls Reduce risk of influenza and pneumoccocal disease through immunization

UPDATE • • • •

• • • • • •

Reduce risk of surgical fires Encourage patientʼs active involvement in their care Prevent healthcare-associated pressure ulcers (decubitus ulcers) Identify safety risks inherent in patient population (suicide, home fires) Rapid response to changes in patient condition (new for 2008) Implementation of Universal Protocol for preventing wrong-site, wrong-person, wrong-procedure surgery

To learn more about the proposed 2009 National Patient Safety Goals, go to and see the News Flash on Page 8 of this issue.

Surgical Care Improvement Project (SCIP): Target Areas

1. Surgical-site infections • Antibiotics, blood sugar control, hair removal, normothermia 2. Perioperative cardiac events • Use of perioperative beta-blockers 3. Venous thromboembolism • Use of appropriate prophylaxis


By the numbers: • 3,740 hospitals are submitting data on SCIP measures, representing 75 percent of all U.S. hospitals • Currently, SCIP has more than 36 association and business partners

CMSʼs 9th Scope of Work is available at SCIP measures are included in the 9th Scope of work. The 9th Scope of Work began August 1, 2008 and runs for three years. To learn more, see the article on Page 13 of this issue.

To learn more, visit

Aligning practice with policy to improve patient care 7

News Flash CMS Proposes Additions to List of HospitalAcquired Conditions for Fiscal Year 2009

On April 14, 2008, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that would update payment policies and rates under the hospital inpatient prospective payment system (IPPS) for fiscal year (FY) 2009, beginning for discharges on or after October 1, 2008. CMS is proposing to select nine categories of hospital-acquired conditions (HACs) for FY 2009 in addition to the eight selected one year ago.

Candidate HACs for 2009 • Surgical site infections following specific elective procedures: total knee replacement, laparoscopic gastric bypass and gastroenterostomy, ligation and stripping of varicose veins • Staphylococcus aureus septicemia • Clostridium difficile-associated disease (CDAD) • Ventilator-associated pneumonia (VAP) • Deep vein thrombosis (DVT)/pulmonary embolism (PE) • Legionnairesʼ disease • Iatrogenic pneumothorax • Delirium • Extreme glycemic aberrancies

Joint Commission Announces 2009 National Patient Safety Goals

The Joint Commission has announced the 2009 National Patient Safety Goals and related requirements for accredited hospitals and critical access hospitals, accredited ambulatory care facilities and offices in which surgery is performed. In addition to the existing National Patient Safety Goals, the following modifications and additions have been made: New: • “Eliminate transfusion errors related to patient misidentification” was added to the “Improve accuracy of patient identification” goal • Accurately and completely reconcile medications across the continuum of care. • “Implement best practices for preventing surgical site infections” was added to “Reduce the risk of health care associated infections.”

The announcement of the additional conditions that are selected will be made at the same time this magazine is going to print. We encourage you to go to to find out which of the 9 candidate HACs were chosen. Look for additional information on the HACs selected for 2009 in the next issue of The OR Connection magazine.

The Results Are In!

Hereʼs what you had to say about The OR Connection

The staff of The OR Connection would like to thank the 582 of you who took the time to complete our online readership survey! Weʼve learned a lot from what you had to say, and we wanted to share some of the results with you! We learned that Patient Safety is the most-read section of the magazine, followed closely by OR Issues. We were excited to learn that 93 percent of you find the information in The OR Connection to be useful.

We also learned a lot about your priorities. Eighty-eight percent of you told us that patient safety is a priority, followed by turnaround time (73 percent), surgical site infection prevention (69 percent), education (35 percent) and new innovation (22 percent).


The OR Connection

Thanks again for your feedback – we look forward to continuing to hear from you in the future!

News Flash

APIC Announces New Name for Infection Control Professionals

To articulate the expanding roles of its members, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that infection control professionals will now be referred to as “infection preventionists.” This newly created term joins the list of professional titles such as hospitalists, intensivists and interventionists introduced by the healthcare industry over the past several years. Infection preventionists direct interventions that protect patients from healthcare-associated infections (HAIs) in clinical and other settings around the world. They work with clinicians and administrators to improve patient and systems-level outcomes and reduce HAIs and related adverse events.

“The term infection preventionist clearly and effectively communicates who our members are and what they do,” said Kathy Warye, APICʼs CEO. “Infection preventionists develop and direct performance improvement initiatives that save lives and resources for healthcare facilities, so this was a natural transition – or a right-sizing of the name – to more accurately reflect their role. By creating a new word, we hope to raise awareness about what infection preventionists uniquely contribute to patient safety, improved outcomes and bottom line savings to healthcare institutions.” To view the complete press release, please visit

Study: Time is of the Essence with Postoperative Indwelling Catheter Use

A recent study found that surgical patients whose indwelling catheters were left in place for more than 48 hours are twice as likely to develop a urinary tract infection, resulting in increased length of stays, hospitalization costs and rehospitalizations. The study, published in the June 2008 issue of Archives of Surgery, is titled “Indwelling Urinary Catheter Use in the Postoperative Period: Analysis of the National Surgical Infection Prevention Project Data.” It was authored by Heidi Wald, MD, MSPH; Allen Ma, PhD; Dale Bratzler, DO, MPH and Andrew M. Kramer, MD.

Data used in the study was collected from nearly three thousand U.S. acute care hospitals participating in the Surgical Care Improvement Project. The study revealed that of the surgical patients who had received indwelling catheters, half had the catheters in place for more than two days. The group whose catheters were left in for more then 48 hours was twice as likely to develop a urinary tract infection. The study clearly demonstrates that urinary catheters in postoperative patients should be removed as soon as possible to decrease the likelihood of an adverse outcome.

To learn more about the study, please visit

Aligning practice with policy to improve patient care 9

Now is the time. This is the opportunity.

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The six conditions targeted by Prevention Above All

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and their complementary Medline product and program

conditions (HACs).

solutions are:

Preventing HACs is one of the most important issues in

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health care today. Simply put, the CMS reimbursement changes taking effect October 1 mean healthcare professionals must eliminate HACs and improve patient safety — or risk losing Medicare reimbursement dollars. The good news is that almost all HACs are preventable, and with Medline’s Prevention Above All, you will have the knowledge and products to prevent six of the most common HACs. The program’s multi-layered approach

• Hospital-acquired infections Hand Hygiene Compliance Program • Pressure ulcers Pressure Ulcer Prevention Program • Harm avoidance and patient satisfaction Educational Packaging • Objects retained after surgery RF Surgical Detection System™ • Catheter-associated urinary tract infections Silvertouch™ Catheter

provides you with targeted evidence-based interventions that will not only save lives but also improve your bottom line.

To learn more about Prevention Above All, contact your Medline representative, call 1-800-MEDLINE or visit us at ©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Invitational Forum Medline presents an executive Prevention Above All forum focusing on the implications of the new CMS guidelines, targeted interventions and practical solutions. Keynote speaker: John Nance, JD A founding member of the National Patient Safety Foundation and one of the foremost thought leaders on change in America’s healthcare system and a regular contributor to ABC World News and Good Morning America, John is also the author of 18 books, including his latest, Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care.

Featured speakers: Deborah Adler

Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN

Senior designer at the design firm Milton Glaser, Inc.

Board certified wound specialist with extensive experi-

and the inspiration behind Target’s ClearRx system

ence in wound, ostomy & incontinence care.

Dr. Dale Bratzler, DO, MPH

Heidi Wald, MD, MSPH

Medical Director of the Hospital Interventions Quality Im-

Assistant Professor of Medicine, University of Colorado

provement Organization Support Center and the Hospital Quality of Care Measures Special Study

Kathy Warye Chief Executive Officer of Association for Professionals in

Larry Creech, RN, MBA, CDT

Infection Control and Epidemiology (APIC)

Vice President Perioperative Surgical Services, Clarian Health Partners Dea Kent, RN, MSN, NP-C, CWOCN

For more conference information, visit

Practicing nurse for 20 years and the manager and primary provider at the Wound Healing Center at St.

• Learn about Prevention Above All

Joseph Hospital in Kokomo, Indiana

• Speaker biographies • Select conference presentations (available 8/20)

Dr. Andrew Kramer Professor of Medicine, Head of Division of Healthcare Policy and Research, University of Colorado

• Request information on specific interventions

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Sterillium® Rub with touchless dispenser pictured. ©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Feature

SCIP’s Role in the CMS 9th Scope of Work Proposal By Dale Bratzler, DO, MPH

Medical director, Hospital Interventions Quality Improvement Organization Support Center and the Hospital Quality of Care Measures Special Study

On August 1, the Centers for Medicare & Medicaid Services launched its next three-year cycle of healthcare quality improvement

initiatives for Medicare providers, known as the 9th Scope of Work

(SoW). Under the direction of CMS, the Quality Improvement

Organization (QIO) Program consists of a national network of 53 QIOs responsible for each U.S. state, territory and the District of Columbia. QIOs work with consumers and physicians, hospitals and other caregivers to refine care delivery systems to make sure

patients get the right care at the right time, particularly patients from underserved populations. The Program also investigates beneficiary complaints about quality of care.

Aligning practice with policy to improve patient care 13

The Patient Safety theme is designed to address areas of patient harm by using established, evidence-based research that improves

healthcare processes and systems. Key areas of focus in the Patient Safety theme include:

• Improve inpatient surgical safety and heart failure rates (SCIP/HF)

• Decrease the rate of pressure ulcers (PrU-Nursing Homes and Hospitals)

• Reduce the use of physical restraints (PR) • Improve drug safety

• Reduce rates of healthcare associated

methicillin-resistant Staphylococcus aureus (MRSA)

• Providing quality improvement technical assistance to nursing homes in need

The focus of the Surgical Care Improvement Project (SCIP) has

been the recruitment of hospitals for participation in the programʼs process measurements. The measurements were defined and

recommended through evidenced-based practice to improve outcomes of surgical patients.


• SCIP Card 2: Surgery patients on a beta-blocker prior to arrival that received a beta-blocker during the perioperative period

Venous thromboembolism

• SCIP VTE 1: Surgery patients with recommended venous thromboembolism prophylaxis ordered

• SCIP VTE 2: Surgery patients who received appropriate

venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery

Facilities participating in SCIP are collecting data and then depositing the data in the CMS Clinical Data Warehouse (CDW), a national repository from which hospital-specific

performance rates are derived for public reporting on Hospital Compare. Additional information is available at: (click on “Statement of Work”) and at

The specific SCIP measures include: Infection

• SCIP INF 1: Prophylactic antibiotic received within one hour prior to surgical incision

• SCIP INF 2: Prophylactic antibiotic selection for surgical patients • SCIP INF 3: Prophylactic antibiotics discontinued within 24

hours after surgery end time (48 hours for cardiac patients)

• SCIP INF 4: Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose

• SCIP INF 6: Surgery patients with appropriate hair removal

14 The OR Connection

About the Author

Dale Bratzler, DO, MPH, has been involved in healthcare quality improvement on the local, state and national level since 1987. Dr. Bratzler currently serves as the Medical Director for the Hospital Interventions Quality Improvement Organization Support Center and the Hospital Quality of Care Measures Special Study.

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repeatable power is available regardless of tissue type. Plus, Bovie Electrosurgical Generators are backed by the longest warranty in the industry. When you add in two cutting modes, ten blend settings, a surgeon preset center and three coagulation modes, it’s easy to see why a Bovie generator is a great choice for your electrosurgical needs – and why it's the generator everyone is talking about! IDS-300 pictured ©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Bovie is a registered trademark of Bovie Medical Corporation.

16 The OR Connection

Eighth in a Series

Back to Basics

Patient Safety

Electrocautery Safety and OR Fire Prevention By Alecia Cooper, RN, BS, MBA, CNOR

It could happen at any time, to anyone and when you least expect it. If and when it does, your patient, you and your coworkers could suffer serious injuries, depending upon the extent and type of error.

The safe and proper use, maintenance and disposal of electrocautery equipment in the operating room should never be overlooked or taken too lightly. If you do, you could be faced with one of the most terrifying experiences of your professional career. Complications and patient injury due to improper use of electrocautery devices include inadvertent and advertent thermal injury, burn, fire, cardiac arrhythmias and interference with pacemakers. Although all are serious complications, a surgical fire can be the most critical.1

Two devastating cases

Following a successful gallbladder surgery at a metropolitan medical center in Boston, a female patient experienced a flash fire ignited on her midsection. The patientʼs abdomen was cleansed following her surgical procedure with an alcoholbased cleansing solution. The surgeon then decided to remove a mole from the patientʼs abdominal area using electrocautery. Blue flames immediately shot up from her midsection – “similar to a flambé,” the surgeon told state health investigators. The patient suffered painful first- and second-degree burns.2 According to the ECRI Institute, 44 percent of operating room fires occur during head, face, neck or chest surgery, when electrical surgical tools are closest to the oxygen the patient is breathing.2

A 68-year-old man was scheduled for ambulatory surgery to remove a skin lesion on his right cheek. A moderate amount of bleeding was encountered during the punch biopsies and an electrocautery device was used to cauterize the skin edges – igniting the nasal cannula and surgical drapes surrounding the face. The surgeon poured sterile water from the operative tables on the patient and the nasal cannula to extinguish the fire. The nasal cannula and drapes were removed from the patient and thrown to the floor. The nasal cannula continued to burn until anesthesia personnel turned the oxygen off. Once the fire was extinguished, new instruments and drapes were obtained. The patient was re-draped and the procedure was completed. A thorough examination indicated first- and second-degree burns involving both cheeks, as well as the right nasal vestibule.3

The history of electrocautery

Cauterization began as a means to stop heavy bleeding, especially during amputations. The procedure was simple: a piece of metal was heated over fire and applied to the wound. This would cause tissues and blood to heat rapidly to extreme temperatures, causing coagulation of the blood and thus controlling the bleeding. Next came medical instruments called cauters, used to cauterize arteries. Electrocauterization (also called electric surgery or electrosurgery) is the process of destroying tissue with electricity. It is widely used in many surgical procedures. The procedure is most frequently used to stop the bleeding of small vessels or for cutting through soft tissue. The electrocautery generator (ESG), more commonly referred to as an electrosurgical unit

Aligning practice with policy to improve patient care 17

(ESU) or simply as a generator, powers an electrosurgical system with electricity at an appropriate voltage, frequency and waveform for cutting or coagulation, as required.


To prevent electric shock, an alternating frequency that is higher than power from standard wall outlets is used. Normal AC “house-current” runs at 50-60 Hz and is quite lethal, since at every alternation nerves and muscles get stimulated, causing violent cramps at 50 to 60 times per second. However, nerve and muscle stimulation cease at 100,000 Hz, due to alterations being too fast for the cells to pick up. Electrosurgery can be performed safely at “radio” frequencies above 100 kHz.4

Cutting vs. coagulation

Different cauterizing effects can be achieved by changing the voltage of the current as well as the pattern of electric pulses. When lower voltage is used with a continuous alternating current (AC), heat is produced very fast and tissue is completely vaporized at the tip of the probe. The effect is “cutting.” When a higher voltage current is used in a pulsed manner, heat is produced more slowly, tissue damage is more widespread and blood coagulates. In many electrosurgery instruments, this is called “coagulation” mode. This is used for ablation. Usually a “blend” setting is available as well.

Monopolar vs. bipolar

Both monopolar and bipolar electrocautery involve highfrequency alternating current and a pair of electrodes, one referred to as “active” and the other “returning.” The difference lies in the placement of the electrodes.

18 The OR Connection


Current is passed from the active electrode, where cauterization occurs, and the patientʼs body serves as a ground. A grounding pad is placed on the patientʼs body, usually the thigh, and it serves as the returning electrode, which carries the current back to the machine. The placement of the return electrode is critical in preventing extensive burns.


The active and receiving electrodes are both placed at the site of cauterization. The probe is usually in the shape of forceps, with each tine forming one electrode, cauterizing only the tissue between the electrodes.


Different shapes of cautery probes are used for different purposes. A common monopolar probe is pen-shaped but ending in a small slender scalpel-shaped spatula of about 5 to 30 mm. This can be used a both a coagulator and an electric scalpel. The typical bipolar probe resembles a pair of tweezers that grasp and cauterize a small piece of tissue. There are variations of these probes that can be used in both open and minimally invasive surgical procedures.

The chance of fire

Electrosurgery electrodes and devices are frequently ignition sources for surgical fires. These types of fires are a potentially devastating yet preventable adverse event. Thankfully, fires in the operating room are not frequent. According to ECRI, only 50 to 100 surgical fires are reported each year – but the fires can result in serious consequences to patients, damage to equipment and interruptions to operations.5

According to one ECRI report, an electrosurgical pencil caused a drape fire because it was not placed in a nonconductive holster.6 In this incident, a pencil fell off the sterile field, was not removed and instead was left dangling. A surgical team member leaned against the pencil, causing it to activate, arc through the drapes to an instrument table and ignite the drapes. The flame spread rapidly up the drapes, vertically from the point of ignition, about two feet off the floor, to the patient. By this time, the fire was burning with such intensity that all other flammable materials on and around the patient ignited and quickly burned. This fire was fatal to the patient. Did you know that that materials burn more quickly when vertical?

There are three conditions that must be in place for a fire to occur: fuel, oxygen and heat. When brought together, these components complete the fire triangle. Preventing a fire in the OR can be achieved by controlling the elements that make up the fire triangle.

Control ignition sources

The most common ignition sources in the OR are electrosurgical and/or electrocautery equipment and lasers. ECRI reports that approximately 68 percent of surgical fires involve electrosurgical equipment and 13 percent involve lasers. We have control over ignition sources.6

ECRI recommends that during electrosurgery6: • Remove unneeded foot switches to avoid inadvertent activation. • Place the electrosurgical pencil in its holster when not in active use and place the electrosurgical unit in the standby mode. • Allow the tip of the pencil to be activated only by the individual wielding it and when it is under direct observation of the surgeon. • Use only active electrode tips that are manufactured with insulating sleeves. • Do not use electrosurgery to enter the trachea. • Do not use electrosurgery in close proximity to combustible materials and oxygen-rich atmospheres. • Dispose of electrocautery pencils properly. For example, break off the cauterizing wire and cap the pencil.

Control oxygen levels

We can control oxygen-rich environments in the OR, which include any atmosphere where there is greater than 21 percent oxygen. While oxygen will not burn or explode, it can cause materials that will not ignite or that burn slowly in ambient air to easily ignite and burn rapidly. The vapor density of pure oxygen (1.1) is slightly heavier than air. This means that pure oxygen may collect in depressions or under drapes or clothing.

Nitrous oxide use can increase effective oxygen levels above 21 percent. Like oxygen, nitrous oxide also has a vapor density greater than 1.0. With a vapor density of 1.53, it will collect in low-lying areas as well.6

ECRI data shows that 74 percent of the reported surgical fires occurred when oxygen levels were elevated above 21 percent. It's important to understand that oxygen may collect and its concentration become elevated. This can occur under surgical drapes, in clothing, on the surface of the skin due to the presence of vellus (short, fine, "peach fuzz" body hair) and around masks, tubes or nasal cannula when patients are provided oxygen or nitrous oxide from compressed gas cylinders or piped medical gas systems.6

To control oxygen concentration levels ECRI recommends6: • That the requirement for 100 percent oxygen for open delivery to the face (for example, when using nasal cannula) be questioned if a lower concentration is consistent with the patient needs. • Stopping supplemental oxygen at least one minute before using electrosurgery, electrocautery or laser surgery on the head or neck. • Titrating the delivery of oxygen to the patient based on the patientʼs blood-oxygen saturation. • Tenting drapes to allow gases to drain away from the operating table. • Using a properly applied incise drape, if possible, to help isolate head and neck incisions from oxygen-rich atmospheres. • Considering use of active gas scavenging of space beneath the drapes during oxygen delivery. When scavenging under the drapes, exercise caution so that the space beneath the drapes doesnʼt collapse. • Avoiding the use of nitrous oxide during bowel surgery.

During oropharyngeal surgery, ECRI also recommends: • Suction be used as near as possible to any potential breathing gas leaks to scavenge the gases from the oropharynx of an intubated patient.

Control combustible materials

Combustible materials – fuel that will burn – surround the patient in the OR and include the operating table bedding, headrests, clothing, straps, towels, drapes, sponges, dressings, hair, intestinal gases, tracheal tubes, body tissue, bronchoscopes, breathing systems, petroleum jelly, adhesives, hoses

Continued on Page 21

Aligning practice with policy to improve patient care 19

Here’s a tip for you. Medline’s exclusive Blue Silk™ electrodes are coated with PTFE, the same non-stick compound used in Teflon®, enabling them to be wiped clean with a wet piece of gauze or sponge instead of an abrasive scratch pad. Blue Silk electrodes also have rounded edges to prevent RF current from concentrating too much energy in one area. All tips shorter than 3 inches in length features ribbed insulation to make swapping out tips easy–even with a slippery pencil or when wearing gloves!

Ribbed insulation

Rounded blade

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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

and equipment covering – and this list is not complete. Flammable and combustible liquids are also present in the OR, including skin prep solutions, tinctures, degreasers, suture pack solutions and liquid wound dressings.

Understanding what can burn and which liquids are flammable or combustible is the first step in managing the fuel load for a potential fire. Allow flammable liquid preps (e.g., preps that are alcohol-based or contain acetone) to fully dry before draping and avoid pooling the liquids when they are applied. Be aware that pooled liquids can be wicked up into sponges, drapes, etc. and may take longer to dry. ECRI recommends that facial hair (e.g., eyebrows, beards and mustaches) be coated with a water-soluble surgical lubricating jelly to inhibit combustion.6

Know and practice the fire plan

Service-specific fire plans have been required for many years. A fire plan is strongly recommend for surgical service. It should be reviewed annually and it is recommended that quarterly fire drills be conducted. Surgical staff members should participate in at least one fire drill (conducted in the OR) every year, and it is especially important to: • Talk about what each OR team member will do if presented with a fire involving a patient. • Walk through the plan and look for areas where response can be improved. • Know who will be responsible for moving the patient, where the patient will be moved and who will be moving critical equipment.

Not all burns are external

Not all fires and burns are external to the patient. Internal fires have been reported in the literature involving patients undergoing laparoscopic procedures in oxygen-rich atmospheres (oxygen was mistakenly used for insufflation instead of carbon dioxide). They have also been caused by the use of lasers and non-metallic endotracheal tubes that were ignited while in the patient. The burning endotracheal tube created a fire similar to that which might have occurred had a blowtorch scorched the lungs.

Stray electrosurgical burns can cause internal injuries that might be difficult to detect because they may not be visible to the surgeon. Figures show that 67 percent of stray electrosurgical burns go unnoticed during surgery and that 25 percent of the patients who suffer internal injuries stemming from these burns during laparoscopic procedures die.7 Insulation failure on the electrosurgical device that results in burns and capacitive coupling is cited as being the primary cause of burns during laparoscopic procedures. With use, the tip of the ESU can become extremely hot and, if inadvertently touched to targeted tissue, can cause burns. Capacitive coupling can occur if there is microscopic insulation failure in the device.

The insulation failure provides an alternate electrical current path between the active electrode and the patient return electrode, resulting in the burn. To minimize capacitive coupling, use an electrosurgical waveform with the lowest voltage necessary to achieve the desired surgical 5 effect. Instruments that use active electrode monitoring technology (AEM) are also effective in preventing capacitive coupling.7 These devices are shielded and monitored so that 100 percent of their power is delivered where intended. Refer to the Forms & Tools section starting on Page 76 to find an Electrocautery Checklist and an Electrosurgical Cautery Safety policy and procedure. For additional support materials regarding fire prevention in perioperative services, refer to AORNʼs guidance statement “Fire Prevention in the Operating Room.”

References 1 Gamal M, Lamont C, Greene FL, eds. Review of Surgery Basic Science and Clinical Topics for ABSITE. New York: Springer; 2006. 2 Kowalczyk L. Fires during surgeries a bigger risk than thought. Available at: _bigger_risk_than_thought/. Accessed July 15, 2008. 3 Joint Commission International Center for Patient Safety. Preventing Surgical Fires: Who needs to be Educated? Available at: Accessed July 15, 2008. 4 Cauterization. Available at: en.wikipedia/wiki/Cauterization. Accessed July 12, 2008. 5 DeRosier JM, Surgical Fires and Patient Surgical Burns. NCPS Tips – August/ September 2003. Available at: 03.doc. Accessed July 14, 2008. 6 Focus on surgical fire safety. ECRI Health Devices. 2003;32(1):4-40. 7 Avoiding Electrosurgical Injury During Laparoscopy: An Emerging Patient Safety Issue. [Videotape] Washington: Communicore; 1997.

Aligning practice with policy to improve patient care 21

Crossword Puzzle

Back to Basics

Electrocautery Safety and OR Fire Prevention 1





























22 The OR Connection 1. Register (free) or log in 2. Click Free Courses tab 3. Locate the puzzle and click Learn More, then Begin Course 4. Certificates are available online after puzzle completion


Across 1 Electrical fires due to the improper use of electrocautery equipment are a potentially devastating yet _____ adverse event. 4 Complications and patient injury due to improper use of electrocautery devices include inadvertent and advertent thermal injury, burn, _____, cardiac arrhythmias and interference with pacemakers. 5 A common monopolar _____ is pen-shaped. 6 Use only active electrode tips that are manufactured with _____ sleeves. 7 Electrocautery is most frequently used to stop the bleeding of small vessels or for_____ through soft tissue. 8 Cauterization began as a means to stop heavy _____, especially during amputations. 9 To prevent electric shock, an alternating frequency that is _____ than power from standard wall outlets is used. 10 The placement of the return _____ is critical in preventing extensive burns. 11 _____ fires have been reported involving patients undergoing laparoscopic procedures in oxygen-rich atmospheres. 13 Preventing a fire in the OR can be achieved by controlling the elements that make up the fire _____. 15 There are three conditions that must be in place for a fire to occur: _____, oxygen and heat. 17 In bipolar cauterization, the active and receiving electrodes are both placed at the site of _____. 21 Remove unneeded foot switches to avoid _____ activation. 24 The typical bipolar probe resembles a pair of _____. 27 Place the electrosurgical pencil in its _____ when not in active use and place the electrosurgical unit in the standby mode. 28 A fire _____ is strongly recommended for surgical service. 29 When a higher _____ current is used in a pulsed manner, tissue damage is more widespread and blood coagulates. 30 _____ what can burn and which liquids are flammable or combustible is the first step in managing the fuel load for a potential fire.

Down 2 Do not use electrosurgery to enter the _____. 3 Do not use electrosurgery in close proximity to _____ materials and oxygen-rich atmospheres. 12 Electrocauterization is the process of destroying tissue with _____. 14 Different _____ effects can be achieved by changing the voltage of the current as well as the pattern of electric pulses. 16 Allow the tip of the pencil to be _____ only by the individual wielding it and when it is under direct observation of the surgeon. 18 Electrosurgery can be performed safely at “radio” frequencies _____ 100 kHz. 19 With _____ cauterization, current is passed from the active electrode, where cauterization occurs, and the patientʼs body serves as a ground. 20 _____ of electrocautery pencils properly. For example, break off the cauterizing wire and cap the pencil. 22 It's important to understand that oxygen may collect under drapes and in clothing and its concentration become _____. 23 _____ reports that approximately 68 percent of surgical fires involve electrosurgical equipment. 25 A grounding pad is placed on the patientʼs body, usually on the _____, and serves as the returning electrode, carrying the current back to the machine. 26 A _____ setting is available with most electrocautery devices which allows for cutting and coagulation.

To receive one hour of CE credit, enter your answers online at Aligning practice with policy to improve patient care 23

The average settlement in malpractice cases involving RFOs is $50,000.2

24 The OR Connection

Patient Safety

Left Behind Retained foreign bodies harm both patients and finances By Megan Giovinco, RN, CNOR, RNFA

A 42-year-old woman presented with a five-month history of abdominal pain, nausea and vomiting. Physical examination revealed a palpable epigastric mass. Five months prior, the patient had undergone an abdominal hysterectomy for uterine leiomyomata. The rest of her examination and history were unremarkable. An abdominal computed tomography (CT) scan was performed. Review of this and the Scout image from the CT revealed a “density consistent with a laparotomy sponge in the left lower quadrant of the abdomen.” The patient returned to surgery for an exploratory laparotomy and a sponge from her first surgery was found and removed.1

How serious is the problem?

Gossypiboma, or retained foreign objects, are a dangerous and costly issue.2 Current studies have found that retention of sponges, sharps or instruments can occur as frequently as one in every 100 cases or 1 in every 5000 cases. According to the American College of Surgeons, any facility that performs 8,000 to 18000 major cases annually will have one incidence of a retained item yearly.3 These statistics are based on claims data, but it is highly probable that even more cases are settled outside the legal system every year. In addition, it is likely that many more circumstances where “near misses” – incorrect counts of sponges and instruments that were identified and resolved intraoperatively via manual searches and X-rays – have happened.4 The average settlement in malpractice cases involving RFOs is $50,000. These items that are inadvertently left behind when the surgical incision is closed can cause pain, sepsis, bowel perforation,

adhesions and death.2 If this was not enough to make surgical facilities reexamine their count policies, the fact that they will not receive their full Medicaid and Medicare reimbursements if they fail to take steps to prevent eight avoidable hospitalacquired conditions – including RFOs – will. In short, if a patient must return to surgery to remove a foreign object left behind during a previous procedure, the hospital will have to foot the bill.5

Traditionally, the manual counting of sponges, sharps and instruments has been a utilized standard of practice in the surgical setting. Although helpful, there is no published data discussing the effectiveness of this practice.4 In fact, according to a study done by the New England Journal of Medicine, in almost 90 percent of cases involving a retained foreign object, a count was performed per policy and all objects were reportedly accounted for.6 Certain assistive devices such as hanging bags to place sponges in, needle boxes on the surgical field and wall-mounted boards for count documentation have helped, but items continue to be left behind.4

How does this happen?

So why do items get left behind? The surgical team is made up of dedicated and conscientious healthcare providers – including anesthesiologists, surgeons, nurses and surgical technicians – who are committed to a common goal of safe, efficient and effective functionality. These professionals constantly execute challenging tasks under considerable time pressures, often in chaotic, constantly changing, stressful situations.4 Although these practitioners have been trained

Aligning practice with policy to improve patient care 25

If a patient must return to surgery to remove a foreign object left behind during a previous procedure, the hospital will have to foot the bill.

and have the experience to deal with such an environment, human error can occur – especially when so many distractions are present.7 Other risk factors that contribute to a greater chance of something being missed include emergency surgery, unplanned changes in the procedure, patients with a high body mass index, multiple changes in the surgical team and multiple operative sites.2

Well, what more can be done? As with many things, communication is key. Good communication between the surgical team is necessary for the prevention of retained foreign objects.8 Intraoperatively, distractions, interruptions, noise and traffic should be as limited as possible. When staff changes occur, complete and accurate transmission of relevant information must be shared. This information should also be documented according to facility policy. Toward the end of the procedure, the final count of surgical sponges, sharps and instruments should be performed and include a visual and audible confirmation by at least two team members. This information should then be relayed to the surgeon prior to closure of the surgical site.4

Although following these guidelines will augment accuracy and reduce errors, the fast pace and everchanging conditions of the OR environment do not always allow for them to take place as well as they would in an ideal setting. It is for this reason that surgical facilities must provide the resources necessary to establish the safest OR environment possible. 4 Counting policies should be re-evaluated, revised and updated as needed in order to adapt them to the specific clinical settings of each particular facility and to keep

26 The OR Connection

them up to date with AORN Standards and Recommended Practices.9 These routine assessments of policy should also include investigating any new tools or procedures available that will increase patient safety and reduce retention of counted items.6 Many institutions encourage obtaining a routine X-ray of any case considered high risk for a RFO, such as traumas or morbidly obese patients.3 However, it has been noted in a recent study that three out of 29 X-rays obtained for an incorrect count falsely reported that no foreign objects were seen on the films.9

Technological advances

New technologies, such as radio frequency identification, have recently been gaining acceptance in many of the nationĘźs ORs. Radio frequency ID-tagged sponges are electronically tagged with a small microchip about 4 x 12 mm in size. This chip is small and sturdy enough that the sponges that house it can be used the same way non-RFID sponges are. Detection is still possible even if the gauze is balled or folded up. One can even clamp directly over this chip without impairing its functionality.10 By passing a hand-held, batterypowered wand over the patient, one can detect whether or not a sponge was left behind.9 These RFID chips are available in sponges, gauze and towels in a variety of sizes. The wand can also be used off the surgical field by the circulator to scan for sponges that may have been inadvertently thrown into the trash.10

This system is not meant to replace the traditional counting system, but to augment it. Since the majority of retained sponges happen when the counts are thought to be correct, a clear scan and a reconciled surgical count give the scrub nurse and circulator the assurance and peace of mind that their findings are also correct.10 Clinical evaluations performed by surgeons and perioperative personnel have rated the RFID systems very highly for ease of use and the possibility of decreasing the risk of incorrect counts.9

Continued on Page 28

Searching for that one last sponge?

The RF Surgical® Detection System™ Perioperative nurses spend 15 to 30 stressful minutes manually counting surgical sponges and instruments before, during and after each operation. Even with such protocols, studies suggest that given the 28.4 million inpatient operations performed nationwide, more than 1,500 cases of a retained foreign body occur annually in the United States.1 According to Harvard University researchers, 88 percent of retained sponge cases falsely recorded a “correct” manual count of sponges at the end of the procedure, leading staffs to unknowingly leave behind sponges in patients. Prevent Retained Surgical Objects RF Detect® is the first easy-to-use scanning system to accurately detect and prevent retained sponges, gauze and towels in patients. No larger than a grain of rice, RF Detect brings major improvements in patient safety to the OR. Reference 1. Popovic JR, Hall MJ. 1999 National Hospital Discharge Survey. Advance data from vital and health statistics. No. 319. Hyattsville, Md.: National Center for Health Statistics, 2001. (DHHS publication no. (PHS) 2001-1250 1-0287.).

Are You Covered? As of October 1, 2008 Medicare will stop paying for objects retained during surgery. Several major insurers are following suit. By helping prevent the occurrence and risk of retained surgical objects, the RF Surgical Detection System sets a new standard of patient care and safety in the operating room and helps you avoid the cost of diagnosis, treatment, re-operation, legal settlement and the time tracking OR disposables. Developed and Manufactured by RF Surgical Systems, Inc. The RF Surgical Detection System is exclusively distributed by Medline® Industries, Inc.

For more information, contact your sales representative or call 1-800-MEDLINE.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. RF Detect® is a registered trademark of RF Surgical Systems, Inc. RF Surgical® is a registered trademark of RF Surgical Systems, Inc.

Performing surgical counts accurately and efficiently is one of the first things taught to perioperative professionals.9 Everyone involved in the surgical procedure shares an ethical, moral and legal responsibility to provide the patient with the safest possible care. This includes assuring that no foreign objects are retained where they can cause pain, harm, further surgery or even death. To do this calls for the following guidelines set up by the American College of Surgeons to be followed:2 • Effective communication among perioperative staff • Consistent application and adherence to individual facility standards for counting procedures • Performance of a methodical wound exploration prior to closure of the surgical site • Use of X-ray detectable items in the surgical site • Maintenance of the most optimal OR environment possible to allow for focused performance of tasks • Use of X-ray and RF technology as indicated to ensure there are no items remaining in the surgical field

There are many variables during the count process that can potentially lead to errors related to retained foreign objects. These include trauma situations, sudden changes in patient status, obesity, noise and traffic in the room and staff changes intraoperatively. However, it is still the number one priority of all members of the surgical team to ensure the patientʼs safety. OR personnel must utilize their knowledge and experience and remain diligent and focused during the counting phases of the surgical procedure so that no patient has to suffer from a retained item.3

About the author Megan Giovinco, RN, CNOR, RNFA, currently a clinical nurse consultant, has been an RN for more than 10 years. Previously, she worked as a nurse at a number of acute care facilities and trauma centers.

28 The OR Connection

References 1 Brown M, Schabel S. Retained laparotomy sponge. Applied Radiology. 2004;33(1). 2 Cedars- Sinai: OR Elimination of Retained Foreign Objects Taskforce. Nothing left behind. Available at: Accessed July 18, 2008. 3 Jackson S, Brady S. Counting difficulties: retained instruments, sponges and needles. AORN Journal. 2008;87(2):315-321. 4 Gibbs VC, McGrath MH, Russell, TR. The prevention of retained foreign bodies after surgery. Bulletin of the American College of Surgeons. 2005;90(10). 5 Brandon G. Rule denying payments for “never events” will force a close look at current practice. AORN Management Connections. October 2007:3(10). 6 The Joint Commission International Center for Patient Safety. Reducing the risk of unintentionally retained foreign bodies. Available at: Accessed July 18, 2008. 7 RF Surgical Systems Inc. Retained surgical objects: costly to avoid and overcome… until now. Available at: Accessed July 18, 2008. 8 American College of Surgeons. [ST-51] Statement on the Prevention of Retained Foreign Bodies after Surgery. Available at: Accessed July 18, 2008. 9 Murdock DB. Trauma: when thereʼs no time to count. AORN Journal. February 2008:87(2):322-28. 10 RF Surgical Systems Inc. Features. Available at: Accessed July 18, 2008.

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Patient Safety

World Health Organization Issues Safety Checklist for Surgical Teams By Laurie Barclay, MD and Brande Nicole Martin

To improve surgical safety worldwide, the World Health Organization (WHO) has released a new safety checklist for surgical teams to use in operating rooms, according to a report regarding the Safe Surgery Saves Lives initiative, published online June 25 in The Lancet and also available on the WHO Web site. These WHO guidelines and checklist are the first edition, and they will be finalized for dissemination by late 2008, after completion of evaluation in 8 pilot sites globally.

"Preventable surgical injuries and deaths are now a growing concern," Margaret Chan, MD, director-general of WHO, says in a news release. "Using the Checklist is the best way to reduce surgical errors and improve patient safety."

High mortality and morbidity of major surgical procedures mandate global public health and surveillance measures to improve surgical safety, especially in low-income areas with limited surgical access. Estimates suggest that about half of surgical complications may be preventable. The Safe Surgery Saves Lives initiative, a collaboration of more than 200 national and international medical societies and ministries of health led by the Harvard School of Public Health, aims to reduce avoidable surgical mortality and morbidity. The newly developed WHO Surgical Safety Checklist provides a set of surgical safety standards applicable to all countries and health settings.

At 8 pilot sites worldwide, preliminary findings from 1000 patients suggest that using the checklist has nearly doubled the

30 The OR Connection

likelihood that patients will receive a higher standard of surgical care, with adherence to these standards improving from 36% to 68%, and to nearly 100% in some hospitals. Better adherence has been linked to significant reductions in surgical morbidity and mortality, although final results are not yet available.

The checklist covers 3 phases of a surgical procedure: before anesthesia is induced, before skin incision, and before the patient leaves the operating room. For each phase, a checklist coordinator confirms that the team has completed the designated tasks before the next phase of the operation occurs. Before induction of anesthesia, key components of the checklist, using the mnemonic "Sign In," are as follows:

• Check that the patient has confirmed their identity, the surgical site, and the procedure to be done and that the patient has given informed consent. • The surgical site should be marked, if applicable. • The anesthesia safety check should be completed. • The pulse oximeter should be placed on the patient and functioning. • Check to see if the patient has (1) A known allergy. If so, these should be documented. (2) An anatomically difficult airway to intubate or aspiration risk. If so, additional equipment and assistance should be available. (3) Risk of more than 500-mL blood loss in adults or 7 mL/kg in children. If so, provision should be made for adequate intravenous access and fluids.

Before skin incision, the checklist uses the mnemonic "Time Out" for the following components:

• Confirm that all team members have introduced themselves both by name and by their role on the surgical team. • The surgeon, anesthesia professional, and nurse should verbally confirm the patient's identity, surgical site, and procedure to be performed.

• Anticipated critical events to be reviewed by the anesthesia team are whether there are any patient-specific concerns.

• Anticipated critical events to be reviewed by the nursing team are confirmation of sterility of the tools, supplies, and field (including indicator results); documentation and discussion of any equipment issues or concerns; whether antibiotic prophylaxis has been given within the last 60 minutes, if applicable; and whether essential imaging is displayed, if applicable.

World Health Organization. Implementation Manual WHO Surgical Safety Checklist (First Edition). Available at:

• The nurse verbally confirms with the team the name of the procedure to be recorded and verifies instrument, sponge, and needle counts, if applicable; labeling for the surgical specimen, including patient name; and whether there are any equipment problems to be addressed. • The surgeon, anesthesia professional, and nurse review the key concerns regarding recovery and management of the specific patient.

• Anticipated critical events to be reviewed by the surgeon are any critical or unexpected steps, estimated operative duration, and anticipated blood loss.

Lancet. Published online June 25, 2008. Reprinted with permission.

Before the patient leaves the operating room, the checklist uses the mnemonic "Sign Out" for the following components:

The WHO notes that the checklist is not intended to be comprehensive but encourages specific modifications and additions appropriate for each local practice.

"Surgical care has been an essential component of health systems worldwide for more than a century," says checklist coauthor Atul Gawande, MD, MPH, a surgeon and professor at Harvard Medical School in Boston, Massachusetts. "Although there have been major improvements over the last few decades, the quality and safety of surgical care has been dismayingly variable in every part of the world. The Safe Surgery Saves Lives initiative aims to change this by raising the standards that patients anywhere can expect." A copy of The WHO Surgical Safety Checklist can be found on Page 86

Aligning practice with policy to improve patient care 31

Moments of Truth How to enact a

culture change at your facility

We hear a lot about culture change in health care these days. Terms like “culture of safety,” a “just culture,” a “safety culture” or the “culture of a high-reliability organization” pepper the conversations of folks talking about patient safety and how to improve it. Just what is culture and how do you go about creating the culture you want?

By Stephen W. Harden

32 The OR Connection

Special Feature

Defining culture

There are numerous definitions of culture. Everyone seems to have their own take on it. After working with over 80 healthcare organizations in the past eight years to help them create and sustain a culture of safety based on the best practices of high-reliability organizations, I have come to believe the definition of culture is this: “The cumulative effect on the organization of the actions of the people within the organization at daily moments of truth.” The heart of this definition is what people do at the daily moments of truth. Intrinsically, you know what a moment of truth is – the tens, if not hundreds, of little decision points every healthcare professional encounters in the course of their daily activities. A decision point is where a choice must be made. You can do “A” or “B.” You can do something or nothing. You can say something or say nothing. You can do it the right way or use a work-around. You can do it mindfully or thoughtlessly. Many of these decisions are decided almost on the subconscious level, sometimes out of habit – without even being aware of deciding.

The formula for culture change

So if we want to change culture, then we must influence what happens at the thousands of daily moments of truth in an organization. There is a simple formula for this. Remember that “simple” does not always mean “easy.” This formula is simple to understand and difficult to follow. The formula for changing culture is this:

Thoughts + Actions + Habits + Character = Culture

Changing culture begins with changing how folks think at the moment of truth. If you can change how they think, affect why they do what they do, then you can change how they act at the moment of truth. If we can change their thinking long enough to affect how they act on a repetitive basis, then we can help them develop habits. Habits are those actions we take almost without thinking – itʼs just the way we “do business” on a personal level. Changing habits changes our character. Character is what we do, again almost at the subconscious level, especially when we think no one is watching or no one will know.

Aligning practice with policy to improve patient care 33

Leading a Change Initiative

"Your success in life isn't based on your ability to simply change. It is based on your ability to change faster than your competition, customers and business." - Mark Sanborn Questions to ask when considering change: • What do we want to change? • Why do we want to change? • How are we going to change? • Will change make things better?

Often, change does not bring about the desired outcome, or is only temporary. Permanently changing the culture of an organization requires taking the right steps in the right order.

Ultimately, culture is determined by the collective character of all of the people in the organization. Their character is determined by their habits. Their habits are determined by how they repeatedly act at moments of truth. Their actions at that moment are determined by how their thought processes have been influenced. So if you want to change culture, you must change character, and if you want to change character you must change habits, and if you want to change habits you must change repetitive actions, and if you want to change actions you must change how people think.

In my experience, the most effective way to change how people think is through leadership actions. These actions include steps such as: • Over-communicating what must be done, how it must be done and why it must be done; • Aligning all of the documents that describe how business is done in the organization with the philosophy of how it should be done; • Public and repetitive acknowledgment and rewarding of the desired actions at the moments of truth; • Consistent coaching for those needing improvement and willing to improve and • Imposing negative consequences for those unwilling to change how they think and act. To change how people act at the moment of truth, training is most effective. “Telling” is not training. Great training that changes actions is experiential, inter-disciplinary, case studybased, allows for practice and offers real-time feedback and reinforcement on performance. Effective training gives both the individual and the team an opportunity to practice the

34 The OR Connection

Is your team resistant to change? Listed below are three key components required to leading an effective change initiative:

1.Planning - Leading a change initiative requires a compelling vision, a plan to achieve that vision, and time to implement the plan. Anticipate potential obstacles and plan for overcoming or avoiding them. Achieve sustainability by anchoring your changes into your organization's culture. Don't forget to schedule in short-term win opportunities within your long-term planning. This will encourage forward movement.

2.Training - Provide training and support during implementation. Plan for training of new-hires and staff turnover as this will help to ensure sustainability. Make certain the proper equipment is available to support your change initiative. You can't successfully run a new software program system-wide when most of your team is still using dinosaurs for computers. Avoid regression by celebrating the "battle won" too soon, but celebrate your teams' successes along the way as this will build confidence. 3.Human power - Are you adequately staffed to lead this change initiative? Do you have champions in place? Are your champions equipped with a common vision? Avoid overburdening an already overburdened team. Consider restructuring and adding new team members to better ensure change and desired outcome. Reprinted with permission from LifeWings. To learn more, visit

Continued on Page 36

Break down the barriers to hand hygiene compliance.

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your skin? By choosing Sterillium® Comfort Gel™, which is proven to increase skin hydration by 14 percent in just two weeks — while still delivering greater efficacy than other alcohol-based hand antiseptics.* Increased efficacy. Incredible comfort. Improved compliance. Sterillium Comfort Gel. * Data on file

References 1 Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386. 2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at: Accessed November 20, 2007.

actions needed in a learning environment so they will skillfully be used at the moment of truth.

To ensure those actions are repeatedly used when needed and therefore made into a habit, hardwired tools are most effective. Tools such as checklists, protocols, communication scripts, standardized communications and briefing guides help people use the right action at the right moment. The tools serve as a forcing function: if the tool is used correctly as part of the consistent daily work flow, the individual has no choice but to take the right action repeatedly and thus develops an effective habit. Little by little, moment by moment, person by person, habits are ingrained and character changes. When character changes, the culture will change. Simple, but not easy. The beauty of the LifeWings methodology is that each of the components necessary to affect thinking, actions and habits are built into our process and our expert facilitators and coaches demonstrate and teach the skills to follow the culture changing formula. Perhaps your initiative will become guided by this quote from Thomas Carlyle:

“Culture is the process by which a person becomes all that they were created capable of being.” As you and I together continue to create and sustain cultures where healthcare professionals are allowed to be capable of all they were created to be, we will truly change the patient safety landscape in this country.

About the author

Stephen W. Harden is President of LifeWings Partners LLC and co-founder of Crew Training International, Inc. (CTI), the parent company of LifeWings. Prior to his position at LifeWings, he was the principal courseware designer of CTIʼs Crew Resource Management (CRM) training for the U.S. Air Combat Command, Air National Guard, Air Force Reserve Command, Italian Air Force, Swiss Air Force, Belgian Air Force, domestic and commercial airlines, construction crews and hospital surgical teams.

36 The OR Connection

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Surgical Site Infections Are you playing your part in prevention? By Dayna Lowe, CST Instructor

Postoperative surgical site infections, also known as SSIs, are quickly becoming the most common type of nosocomial infection in patients undergoing surgery. They can lead to increased morbidity, mortality, length of hospital stay and healthcare costs.1 These infections number approximately 500,000 per year, among an estimated 27 million surgical procedures.2 Postoperative surgical site infections account for about one quarter of the estimated 2 million nosocomial infections in the United States annually.3

Everyone has a part to play in prevention

Postoperative surgical site infections are not to be taken lightly. The occurrence and nature of SSIs vary from facility to facility, surgeon to surgeon as well as from patient to patient. For the operating room team, the warlike struggle against SSIs is complex. Each team member caring for the surgical patient plays an important role in the prevention of postoperative surgical site infections. Surgical technologists, nurses, anesthesia care providers and surgeons alike can greatly impact the outcome of each surgical procedure by following the structured protocol proven to prevent postoperative surgical site infections.

The surgical technologist

Surgical technologists have the primary responsibility for maintaining the sterile field and remaining vigilant in verifying that all members of the team adhere to an aseptic technique.4 Without this constant vigilance by the surgical technologist, the occurrence of inadvertent contaminations could go unnoticed and ultimately lead to a postoperative surgical site infection. The dedication of the surgical technologist to uphold this responsibility is known as a “surgical conscience.” A surgical conscience is defined as “the ethical and professional motivation that regulates oneʼs aseptic technique.”5

Along with a surgical technologistʼs close watch over the operative field, the tech must be aware of which surgical procedures require a clean and dirty instrument setup. For example, in a procedure involving the gastrointestinal tract, the surgical technologist is presented with the challenge of maintaining a clear definition between instruments involved with the contaminated portion of the procedure and the portion of the procedure that must remain sterile. In order to do so, the surgical technologist must provide the members at the surgical site with a sterile basin dedicated to the reception of the contaminated instruments just before the surgeon opens the bowel.6 Throughout the duration of this portion of the procedure, it is imperative that the surgical technologist does not come in contact

Surgical technologists, nurses, anesthesia care providers and surgeons alike can greatly impact the outcome of each surgical procedure by following the structured protocol proven to prevent postoperative surgical site infections.

with the instruments intended for use after the anastomos is is completed.

This technique requires knowledge of anatomy as well as exceptional organizational skills. A surgical technologist with a healthy surgical conscience and a general understanding of the surgeries in which they partake is a valuable team player in the fight against SSIs.

The circulating nurse

Prior to undergoing a surgical procedure, the patient is prepared for surgery by the circulating nurse. This preoperative routine carried out by the circulating nurse often involves hair removal and decontamination of the surgical site. It is believed that preoperative surgical site hair removal reduces infection rates; in contrast, some methods of surgical site hair removal have been found to increase the likelihood of SSIs.7 For this reason, healthcare facilities have begun using electrical clippers verses the old-fashioned method of dry shaving with a razor. In addition to hair removal, the circulating nurse is most often responsible for the decontamination of the patientʼs skin with an antiseptic solution. The purpose of the skin preparation is to reduce and ultimately remove pathogenic transient microorganisms from the epidermal and dermal surfaces.5 The Association of peri-

Aligning practice with policy to improve patient care 37

Operative Registered Nurses states that when selecting antiseptic agents, one should take into consideration the types of tissue involved. AORN emphasizes that one should choose an agent with a broad range of germicidal action and also apply it in accordance with the manufacturerʼs written instructions.

THESE INFECTIONS number approximately 500,000 per year, among an estimated 27 million surgical procedures.2

The circulating nurse also plays a crucial role in maintaining the patientʼs body temperature, which can greatly influence the risk of SSIs. Although it seems more of a courtesy than structured protocol, the provision of warm blankets can ensure the patientʼs core temperature is at the homeostatic state at the time of induction.

The anesthesia care provider

Attention to the patientʼs body temperature is a standard of care in anesthesia management. Operating rooms are kept at a cool temperature because it has long been believed that doing so minimizes the risk of infection. Recent studies suggest that this is not the case at all. Lowering the core body temperature causes dermal vasoconstriction and reduced blood flow to surgical sites, thus taking away life-sustaining oxygen.8 Both regional and general anesthesia can cause the bodyʼs core temperature to drop. In an attempt to prevent intraoperative hypothermia, the anesthesia care provider often employs the use of a forced-air warming blanket. Another action the anesthesia care provider takes that aids in the patientʼs ability to avoid an SSI is the administration of the prophylactic antibiotic(s) in a timely manner. In fact, two national organizations, the Centers for Disease Control and Prevention (CDC) and the American Society for Health System Pharmacists (ASHP), have recently collaborated to provide medical caregivers with guidelines regarding the administration of prophylactic antibiotics for a variety of procedures.9,10 Administration of antibiotics, usually intravenously, should be timed so that a bactericidal concentration is present in blood and tissues by the time the surgical incision is made and maintained until closure of the surgical site. Because of the overwhelming positive impact of the studies done on the administration of prophylactic antibiotics, it is now a standard of care and recommended practice in most healthcare facilities.

In addition to the responsibilities discussed above, the anesthesia care provider is accountable for monitoring the patientʼs blood oxygen saturation. Decreased oxygen levels devitalize tissue and increase the risk for bacterial colonization.11 Providing the patient with an oxygen supplementation involves the delivery of 80 percent oxygen and 20 percent nitrogen through the use of an endotracheal tube, a sealed mask, a manifold system or a conventional non-rebreather mask for the first two hours of recovery. Oxygen is increased to 100 percent

38 The OR Connection

immediately before extubation, with the concentration returned to 80 percent by the anesthesiologist.12

The surgeon

The surgeon is the individual most responsible for prescribing the preoperative antibiotics. Preoperative administration of antibiotics is a course in prevention. The rationale suggests that if there is an infusion of antibiotics in the tissue prior to incision, there is less of an opportunity for opportunistic bacteria to find a home in the patientʼs surgical incision. An intricate combination of timing, selection, duration and discontinued use is vital to the success of an antibiotic.

In a successful surgery, each individual team member plays an important role. Although certain tasks and preoperative routines are delegated to the staff, a system of accountability is useful to maintain an ideal approach to preventing SSIs. A medical caregiverʼs continued education in the advances in aseptic techniques, and overall prevention of surgical site infections, can help ensure a smooth, infection-free recovery for the patient. About the author

Dayna Lowe has been a surgical technologist for six years. She currently works at a smaller hospital in Florida and as an Instructor of Surgical Technology at Central Florida Institute. References 1 Perl T. Identification of Risk Factors Associated with Surgical Site Infection following Spinal Surgery. Study currently underway at Johns Hopkins University. 2 Centers for Disease Control and Prevention. National Center for Health Statistics. Detailed Diagnoses and Procedures, National Hospital Discharge Survey, 1994. Hyattsville, Md.: Department of Health and Human Services; 1997. 3 Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nationwide nosocomial infection rate: a new need for vital statistics. Am J Epidemiol. 1985;121:159-67. 4 Commission on Accreditation of Allied Health Education Programs. Surgical Technologist. Available at: Accessed July 1, 2008. 5 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. St. Louis, Mo.: Elsevier Saunders; 2005. 6 Alexander FM. Maintaining a sterile field during gastro-intestinal surgery. The American Journal of Nursing. 1952;52(6):705-07. 7 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004122. 8 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgicalwound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334:1209-15. 9 American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm.1999;56:1839-88. 10 Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Guideline for prevention of surgical site infection. Am J Infect Control. 1999;27:97-132. 11 Hopf HW, Hunt TK, West JM et al. Wound tissue oxygen tension predicts the risk of wound infection in surgical patients. Arch Surg. 1997;132:997-1004. 12 Greif R, Akca O, Horn EP, Kurz A, Sessler DI. Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. Outcomes Research Group. N Engl J Med. 2000;342:161-67.

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Great Ideas from Your Peers

Surgical Skin Prep Solutions

At St. Vincentʼs Medical Center in Indianapolis, Indiana, Paul Durgan, staff educator for surgery, came up with an innovative way to assist surgical personnel in providing the most effective prep solution in an efficient and cost-effective manner. Paulʼs goals were to offer a high-efficacy surgical prep solution while simultaneously reducing the waste associated with the facilityʼs current prep kit. He had observed staff members discarding most of the contents in their current prep tray and adding their preferred solution.

The CDC strongly recommends using 2 percent chlorhexidine (CHG) solution for skin antisepsis. Two percent chlorhexidine solution has been shown to be six times more effective than alcohol and povidone-iodine in cleaning the skin and in inhibiting microbial growth for days afterward.1 In two studies measuring persistent efficacy, chlorhexidine demonstrated significant residual antimicrobial effects for five days and was more effective than isopropyl alcohol, alcohol or povidone-iodine alone.1 Paul had the opportunity to attend a seminar in which Dr. Allan Morrison Jr., an epidemiologist and chairperson of Infection Control at Inova Fairfax Hospital and clinical assistant professor at Georgetown University Hospital, discussed the benefits of chlorhexidine as a surgical prep

40 The OR Connection

By The OR Connection staff

solution, particularly as it relates to reducing facilityacquired infections following surgical procedures.

This led to the idea of creating a custom surgical prep tray that only contained supplies that could be used in almost every procedure. Of course, Paul wanted to be sure that chlorhexidine was the preferred prep solution, so they choose a four-ounce bottle containing 4 percent CHG. Additional components in the tray include 100 ml saline (for diluting or rinsing), three sponge sticks, six winged sponges, two cotton swab applicators, two blue cloth towels and two white cloth towels. They chose cloth towels for better absorbency and also because they have much less memory than a paper towel, which can spring back after placement and lead to cross contamination.

Creating a custom surgical prep tray enabled St. Vincent’s to realize a 29 percent cost savings over their previous trays. They lowered their per-tray cost by $2.78.

Because CHG cannot be used to prep eye, ear or genital procedures, the need for additional prep solutions is apparent. Paul is actively searching for a CHG prep that can be used on genital areas and will let us know when he finds his next solution.

OR Issues

St. Vincentʼs orthopedic department has also recently initiated a study with their total joint patients, asking them to shower with CHG the night before their surgery. The CDC also recommends that surgical facilities require patients to shower or bathe with an antiseptic agent at least the night before surgery.2 Additional information will be shared as the results of this study become available.

Components of the Custom Surgical Prep Tray • Four-ounce bottle of 4 percent CHG • 100 ml saline (for diluting or rinsing) • Three sponge sticks • Six winged sponges • Two cotton swab applicators • Two blue cloth towels • Two white cloth towels.

Improved efficiency, decreased waste, better patient care and cost savings are all the results of one innovative change. Whereas there is often a perception that customization leads to increased cost, when you find that standardized solutions result in throwing away supplies that are not wanted or used, one can easily see where customization can provide a cost effective solution.

Paul Durgan has been the staff educator for surgery at St. Vincentʼs Medical Center in Indianapolis, Indiana, since 2005. Paul says that this position has helped him “attain a broader perspective of current needs for patient care as well as physician and associate satisfaction.” He credits the development of the CHG prep kit as an area in which he was able to promote a costeffective solution to one of his facilityʼs needs. References 1 Hibbard J et al. A clinical study comparing the skin antisepsis and safety of ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. Journal of Infusion Nursing. 2002;25(4):244-49. 2 Nichols RL. Preventing surgical site infections: A surgeon's perspective. Emerging Infectious Diseases. 2001;7(2).

Aligning practice with policy to improve patient care 41

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Patient Safety

Flipping the Switch on Pressure How to help reduce your patients’ pressure ulcer risk By Jayne Barkman, RN, CNOR

After a leisurely lunch in the outdoor cafĂŠ, Sandy and Joe checked their afternoon assignment. They were to relieve the staff in OR 31. Sandy and Joe entered the OR through the sterile core as the surgeon was initiating the time-out. Joe opened his gown and gloves while Sandy received report from the circulating nurse. The patient was a young anorexic woman with no known allergies who was undergoing a right thoracoscopy and chemical pleurodesis for recurrent pneumothorax. She was positioned in a lateral position right side up on a bean-bag positioner. A towel roll was placed under her axilla. Her arms were padded with foam and pillows and secured on arm boards with two pillows placed between her legs. She was secured to the OR bed by a safety strap across her thighs as well as tape across her hips. After he was gowned and gloved, Joe handed Sandy the light and camera cords. The surgeon asked for the room lights to be

dimmed and then the case was underway. This will be a quick case, Sandy thought to herself as she opened the vial of sterile talc to the field. She finished her computerized charting and, within what seemed like minutes, Joe was ready to do the first closing count. After they completed their counts, Sandy opened the chest drainage tubing to the sterile field and filled the chest drain with water. The second counts were completed soon after and Sandy called for moving and lifting help as Joe placed the dressings over the small incision sites. Joe removed the drapes from the patient as the surgical assistants brought the stretcher into the room and stood at the side of the operating room table in preparation for repositioning of the patient for extubation.

Joe asked Sandy to step around to his side of the OR bed. He pointed to an area where a portion of the draw sheet covering

Aligning practice with policy to improve patient care 43

the bean-bag positioner had Sandy agreed and said she would shifted during the procedure and talk to Sue, the director, to get the the decompressed bean bag in-service scheduled as soon as was pressed directly against the possible. when positioning the patient that patientʼs skin. The standard of all potential pressure points are How to take the pressure care at their hospital for lateral off your patients positioning of patients included adequately padded as well. In the perioperative environment, placing foam padding between nurses are presented with myriad the patient and the bean bag as challenges when caring for their well as placing a gel roll under the axilla and foam padding under the patientʼs heels. After the patients. Careful attention is given to keeping the patientʼs bean bag was compressed to reposition the patient, Sandy and body in proper alignment when positioning in order to prevent Joe assessed the patientʼs skin. A three-inch-long reddened postsurgical neuropathies. It is imperative when positioning area was noted along the patientʼs mid-thoracic spine where the patient that all potential pressure points are adequately padded as well. When using linens, such as blankets and towels, the bean bag had come into direct contact with the skin. for rolls or positioning devices or placing a patient on a thin OR When the anesthesiologist was ready, the patient was lifted and mattress, you could inadvertently be placing your patient at risk for placed in a supine position. Sandy assisted the anesthesiologist pressure ulcer formation. Linens, which are readily available in with extubating the patient and asked Joe to assess the most operating rooms, are often used for positioning patients patientʼs ankles and feet for any pressure areas. Joe noted a but do not reduce pressure and may result in unrelieved areas quarter-sized reddened area on the patientʼs left lateral of pressure or friction injuries.1 mallelous. When the patient was rolled onto her right side to place the transfer device under her, Sandy noticed a plum-sized Studies have indicated that when the reddened area below her left axilla, yet another pressure area. patient is unable to move during The patient was lifted onto the stretcher and transported to the CVICU. When relaying report to the CVICU nurse, Sandy surgery, it is important that the pointed out the reddened areas on the patientʼs back, left axilla weight of the patient be uniformly and ankle as pressure points that needed close monitoring distributed on a firm, stable surface postoperatively.


Back in the OR and helping with room turnover, Sandy and Joe shook their heads. The hospital policy clearly indicated that foam or gel pads were to be used to pad areas of potential pressure on all surgical patients. As representatives on the patient care council, Joe and Sandy were aware that an order had been placed for additional gel rolls and pads – as these items had virtually disappeared from the OR – and that new pressure-free operating table mattresses had been ordered for each of the operating rooms to replace the old table pads, some of which were cracked and repaired with tape. Pressure ulcer prevention had also been added to the hospitalʼs required annual competency education for 2009. Joe suggested to Sandy that the next OR in-service be dedicated to an interactive positioning in-service where staff volunteers were placed in various positions and could verbally relay to their coworkers the areas that felt uncomfortable so the staff had an understanding of direct areas of pressure patients experience when positioned during their surgical procedures.

44 The OR Connection

that conforms to the patient, such as a gel or thick foam mattress pad.2

The amount of pressure and the length of time pressure is applied to the skin are both critical factors in pressure ulcer formation. Studies have indicated that high pressure for a short time and low pressure for a longer duration have the same effect on potential tissue damage and the likelihood of pressure ulcer formation.2 When pressure is applied to the skin, blood flow is decreased, leading to potential skin breakdown and tissue necrosis.3

While extrinsic factors such as shear, force friction and pressure predispose a surgical patient to the development of pressure ulcers, intrinsic factors such as the patientʼs nutritional status, age, mobility and mental and continence status also place the surgical patient at risk of pressure ulcer formation. Recent research, however, has indicated that pressure may be the single most important factor in the formation of pressure ulcers intraoperatively.3

Intraoperatively Acquired Pressure Ulcers4,5,6

About the author

• Initially appear as a burn like lesion. • Occur most frequently in patients undergoing general, thoracic, orthopedic, cardiac and vascular procedures. • Have been documented to occur in 12 percent to 66 percent of surgical patients. • Account for 42 percent of nosocomial-acquired pressure ulcers. • Add an additional cost of up to $60,000 per patient or 750 million to 1.5 billion dollars annually.

Jayne Barkman, RN, BSN, CNOR, has 29 years of perioperative experience in various roles, including surgical technologist, staff nurse and clinical educator. She currently works as a clinical nurse consultant.

Typically, perioperative nurses have no contact with the patient postoperatively and therefore the ramifications of intraoperatively caused pressure ulcers are unknown to the perioperative staff. The Association of periOperative Registered Nurses (AORN) recommends doing a thorough preoperative interview and assessment to determine the appropriate positioning devices required for each individual patient. Their guidelines state that the perioperative nurse should be involved in positioning the patient as well as monitoring for proper body alignment and the tissue integrity of the patient after positioning and during the surgical procedure. A skin assessment should be repeated when the procedure is finished with documentation of the assessment. The recommended practices also state that positioning policy and procedures should be accessible to the staff and be reviewed and revised annually.1

References 1 AORN. Recommended practices for positioning the patient in the perioperative practice setting. In: Standards, Recommended Practices, and Guidelines. Denver, Colo.: AORN, Inc; 2006:587-590. 2 Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention: An analysis of bedding materials. Research in Nursing & Health. 1994;17(5):333-39. 3 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB, Gebhart GH, Ma EK. Pressure ulcer prevention. J Long Term Eff Med Implants. 2004;14(4):285-304. 4 Pressure Ulcers Risk Analysis (Healthcare Risk Control November 2006). Available at: safety_center/ pressureulcers.pdf. Accessed July 23, 2008.

5 Ankrom MA, Bennett RG, Springle S et al. Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems. Advances in Skin & Wound Care. 2005;18(1).

6 Wilhelmi BJ. Pressure Ulcers, Surgical Treatment and Principles. Available at: Accessed July 23, 2008.

Aligning practice with policy to improve patient care 45

Patient Safety

46 The OR Connection

By Claudia Sanders, RN, CFA


Five pressure ulcer factors to keep in mind

Pressure ulcers can develop within two to six hours of the onset of pressure. Incidence is over 60 percent for high-risk patients with femoral and/or hip fractures. Elderly patients with hip fractures have the greatest incidence of new-onset postoperative pressure ulcers, which typically occur within the first two postoperative days. About 70 percent of all pressure ulcers occur in people older than 70 years. Have you had a patient in your OR lately who was 70 years old with a hip or knee fracture? There are many contributing factors for pressure ulcers, including: • Circulation • Mechanical stress • Temperature • Too wet/ too dry (moisture) • Infection • Chemical stress • Medications • Disease • Nutrition • Age • Body build

A number of these factors are out of our control, but others can be affected positively with the appropriate tools and practices. Following is a list of five of these factors and some considerations you will want to examine the next time you are caring for patients at risk for pressure ulcers.

1. Age

It should come as no surprise that the older we are, the more fragile our skin becomes. Skin becomes thinner, drier and has a tendency to break down easily. The elderly are also at a higher risk for poor circulation. Clearly, these patients need to be handled with gentle and caring hands.

Keep in mind how long you may have this patient lying on a stretcher in a holding area. Ask the patient to move themselves if possible or encourage and help move the patient if they are lying in one position for long periods of time. And pad those areas where pressure ulcers most commonly occur when patients are lying down: back of the heels, knees, buttocks, tailbone and hipbone. Same goes for when you have brought the patient into the operating room and placed him on the operating room bed. Proper positioning of the patient and padding of bony prominences is vital in preventing pressure ulcers while patients are in surgery. Your facility may want to invest in gel table pads for stretchers and operating room beds as well as gel positioners.

Aligning practice with policy to improve patient care 47

2. Body build

There are two body types that are especially susceptible to pressure ulcers: obese patients and extremely thin patients. Obese patients are a higher risk due to poor circulation to fatty tissues. Poor circulation means less oxygen, reduced nutrition and more risk for pressure ulcers. When appropriate, be sure to use compression stockings to help with circulation and, of course, assist in preventing deep vein thrombosis (DVT). Do whatever you can to improve circulation. This may mean using minimal sutures in the subcutaneous layer. Handle obese patientsʼ tissues with care and consider preoperative and postoperative oxygen use. Extremely thin patients are also at risk because there is less fatty tissue to “cushion” them. This means their bony prominences are even more susceptible for skin breakdown compared to the average-sized patient. We cannot overstress the importance of padding these areas and padding them with care so as to reduce friction that can lead to skin breakdown.

3. Chemical stress on wounds

As with all surgical procedures, we must first prep the area where the incision will be made. This requires chemical products of one kind or another, depending on the surgeonʼs preference. Such chemicals may include povidone-iodine, hydrogen peroxide, alcohol, acetic acid or iodophors. All these chemicals have an important part in reducing infection, but at the same time they can contribute to skin breakdown. This is a great time to “think outside of the box” and consider what compromises the patient has before choosing your preps. In conditions of extremely compromised skin, consider rinsing with a prep solution and monitor how hard you rub or clean the operative site.

4. Too wet/ too dry (moisture)

Most of us know the story of Goldilocksʼ search for porridge and a bed that were “just right.” Well, the skinʼs moisture needs to be “just right” as well – not too wet and not too dry. When caring for surgical patients, we need to help maintain this environment by being mindful of the solutions we use and how we use them. Donʼt let prep solutions “pool” on or around the patient. Prep solution can often run down into the creases of the femoral, buttocks and lower back areas, not to mention the axillary and neck areas. Do what you can to prevent this and clean these areas before sending the patient to the recovery room so these chemicals will not continue to sit on the skin. Be gentle with this process, especially with the compromised patient.

48 The OR Connection

5. Infection

When caring for surgical patients with infection, there are extra considerations to keep in mind. You know your patientʼs skin is already compromised by infection and that their immune system is also compromised. This compromises healing, which can set patients up for pressure ulcers. To help prevent pressure ulcers from forming, position the patient properly (and pad bony prominences), help maintain good body temperature (keep the OR at a reasonable temperature) and help maintain the ideal skin moisture environment (if necessary, use pads to help wick moisture from the patient). Of course, you also want to prevent cross contamination of infection from an open wound to other parts of the body. Consider using skin barrier-type products on the surrounding areas before prepping an infected wound. Keep in mind that this is an area we have all dealt with at one time or another – but with the occurrence of these pressure ulcers on the rise and changes to reimbursement policies, it is time to revisit our practices. About the author

Claudia Sanders, RN, CFA, is currently a clinical nurse specialist. She has practiced in the medical field for more than 30 years as a surgery technologist and perioperative nurse.

Join the program to reduce pressure ulcers. Medline’s Pressure Ulcer Prevention Program Systematic efforts at education, heightened awareness and specific interventions by interdisciplinary healthcare teams have demonstrated that a high incidence of pressure ulcers can be reduced.1 The main challenges to having an effective pressure ulcer prevention program are lack of resources, lack of staff education, behavioral challenges and lack of patient and family education.2 Medline’s comprehensive Pressure Ulcer Prevention Program offers solutions to these challenges to promote the reduction of pressure ulcers with clinical and educational resources, assessment tools and a complete compatible product line,

The Pressure Ulcer Prevention Program from Medline will help you in your efforts to reduce pressure ulcers in your facility. The program includes: • Education for professional staff and nurse technicians • Teaching materials for you to help train your staff • Practical tools to help reduce the incidence of pressure ulcers • Innovative products supported by evidence-based information that results in better patient care

To join the fight against pressure ulcers and for more information on the Pressure Ulcer Prevention Program, please contact your Medline sales representative or call 1-800-MEDLINE.

designed to work alone or complement your existing program.

The Pressure Ulcer Prevention Program. Pressure ulcer prevention made easy. References 1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29. 2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

The History of the


OR Issues

By Jennifer Bray, SST and Greg Warino, SST

The workplace is full of a wide variety of job titles and initials to place behind your name. They often sound significant, but did you ever wonder where they came from? What caused a need for the professions (and professionals) of today? At some time, every vocation was new, including that of the surgical technologist. So what spurred the need for them?

The advances in medical technology, from antibiotics to blood transfusions, have often come during times of war. This same setting fostered the need for surgical technologists. Initially, the role of the nurse basically entailed assisting the surgeon during procedures. However, as various wars depleted nursing resources, other ways of providing patient care during surgery had to be explored.1 In 1939, Dr. Thomas Parran Jr. (then the U.S. Surgeon General) proposed the Protective Mobilization Plan, which pushed for the training of enlisted medical and surgical

technicians. According to this plan, schools were to be established at the Army Medical Center and four other general hospitals for the formal education of surgical technologists. Prior to this, technicians were simply trained on the job.2

It was not until 1940 that Dr. Parranʼs plans began to be executed. In 1941, the first school of surgical technology was in session. By July of 1942, 410 students were enrolled. With the entrance of the United States into World War II, there was an even greater need for surgical personnel. More schools were quickly established and the number of “scrubs” more than doubled in order to meet the demand of the military hospitals both at home and abroad.2

The nursing shortage worsened as the war continued and more and more wounded soldiers were in need of care. Nurses were in great demand to staff not only local facil-

What Does a Surgical Technologist Do? What roles do surgical technologists play on any given day?*

In the OR, they • Prepare patients for surgery - draping, positioning and establishing the sterile field • Set up surgical instruments and equipment • Gloving • Pass instruments and sterile supplies to the surgeon • Ensure the integrity of the sterile field throughout the procedure • Cut sutures • Perform surgical counts of sponges, needles, supplies and instruments

• • • •

Prepare, care for and dispose of specimens Apply dressings Operate lights and suction machines Assist with diagnostic equipment

Outside of the OR, they • Manage central supply departments • Represent surgical instrument manufacturers and sterile supply services

* Association of Surgical Technologists. The Surgical Technologist. Available at: Accessed June 17, 2008.

Aligning practice with policy to improve patient care 51

ities but the hospitals and medical units of distant military bases and battlefields as well. Because of this, more corpsmen were trained to assist surgeons during procedures. They were also trained to perform tasks such as anesthesia administration, instrument preparation, aid in clamping and retraction intraoperatively and closure of surgical incisions. The title Operating Room Technician, or ORT, was established.1

Early education

erative Registered Nurses (AORN) was formed. This group would play a major role in the development of the surgical technologist into a formal part of the surgical team.4 In 1968, AORN formed the Association of Operating Room Technicians (AORT) and formal training for surgical technologists began at proprietary schools. AORN also helped establish certification credentialing for surgical technologists. The AORT initiated the first certifying exam and gave those who passed it the title of Certified Operating Room Technician (CORT).1

In the beginning, medical and surgical technologist students were taught together for the first month and then In 1972, the American Medical Association formally separated for their clinical instruction. Surgical technologists approved an educational program for the OR technician. In 1978, the Association of were assigned to hospital Operating Room Technicians wards or a surgical service. changed its name to what it is According to the Surgeon now known as – the AssociaGeneralʼs plan, the surgical tion of Surgical Technologists.5 course was to only take two months. However, it was From the humble beginnings quickly determined that more of nothing but on-the-job traintime was needed to train ing to a nationally recognized these students effectively. association and credentialing In 1943, the course was certification, the profession of extended to three months the surgical technologist has with only a month of on-the- Authors Greg Warino, SST and Jennifer Bray, SST are currently enrolled in the surgical technologist program certainly come a long way. In job training.2 at Central Florida Institute in Clearwater, Fla. the years since Dr. Parranʼs In 1942, advanced training was offered to select individuals original plans were developed, hundreds of schools of who had completed the surgical courses. These technol- surgical technology have been established throughout the ogists were prepared to replace nurses in the forward United States and thousands of students have graduated. combat areas or to become instructors of future students. Many of these students have also gone on to earn their Most of their training was provided by nurses in the hospital certification as a surgical technologist (CST), their First setting. Unfortunately, despite the specialized training and Assistant qualification (CFA) or become instructors.5 The service these advanced practice technicians provided, professionals who carry these initials behind their names they were never recognized by the military. This training have this amazing historic timeline to thank for the rewarding career they have chosen. ceased in 1945.3

Moving into the modern day

Since the infantry was depleting the Medical Corps of its male technologists, the department began accepting women into its programs in 1943. The Surgeon General requested the recruitment of even more women in 1944. So many women answered the call to duty that schools of surgical technology had to be expanded yet again.3

The nursing shortages caused by World War II and the wars that followed it forced operating room supervisors to question the need for trained non-nursing personnel to assist during surgery. In 1949, the Association of periOp-

52 The OR Connection

References 1 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. Philadelphia, Pa: W.B. Saunders; 2005. 2 Office of Medical History, Office of the Surgeon General. Medical Department, United States Army Medical Training in World War II. Available at: Accessed June 17, 2008. 3 Association of Surgical Technologists. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 3rd edition. Clifton Park, NY: Delmar Learning; 2008. 4 Association of periOperative Registered Nurses. AORN History. Available at: Accessed June 17, 2008. 5 Association of Surgical Technologists. About AST. Available at: Accessed June 17, 2008.

Medline’s Hand Hygiene Compliance Program

For all the lives you touch. Now more than ever, hand hygiene compliance is crucial.

The Hand Hygiene Compliance Program includes:

Beginning October 1, 2008, the Centers for Medicare &

• An instructor’s manual that takes the guesswork out of

Medicaid Services will no longer be reimbursing at a higher DRG for eight hospital-acquired conditions, including catheter-associated urinary tract, surgical site and blood1

planning lessons • A customizable plug-and-play CD that contains presentations, posters and more

stream infections. We know that hand

• Forms and tools to serve as reminders and reinforcements

hygiene is the number one

• A cost calculator to help you determine the cost of

line of defense against hos-

prevention vs. the cost of an infection

pital-acquired infections.2

• A rewards program to recognize those who complete

There’s no such thing as

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• A how-to guide on enhancing your presentation skills

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For an on-site presentation of the Hand Hygiene Compliance Program and our Healthy Hands Product Bundle, contact your Medline representative or visit

References 1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and fiscal year 2007 rates. Available at: Accessed November 20, 2007. 2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at: Accessed November 20, 2007. ©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Special Feature

A Place of Healing? Violence is increasingly common in health care By Laura Kuhn The OR Connection staff writer

Itʼs ironic when you stop and think about it – hospitals are places where patients go to get better, yet for some healthcare employees theyʼre also places fraught with intimidation, harassment and even violence.

The extent of the problem

According to the Council on Surgical and Perioperative Safety (CSPS), violence in the healthcare workplace is a growing concern and nurses are at a particularly high risk.1 Between 1996 and 2000, there were 69 homicides reported in the health services field.2 Twenty-five of every 10,000 full-time nurses were injured in workplace assaults in 2000. In contrast, injuries due to workplace assaults occur in only two of every 10,000 employees in most private-sector industries.2

As disturbing as these numbers are, it is estimated that the actual number of incidents is much higher.2 Violent incidents often go unreported, possibly due to the perception that assaults are “part of the job” in the healthcare industry.2 Other reasons for underreporting include the lack of a solid institutional reporting policy, the belief that reporting will not benefit the employee and the fear that the report could be viewed by employers as employee negligence or poor job performance.2

Many patients who are treated in hospitals and other care facilities are at an increased risk of exhibiting violent behavior. 54 The OR Connection

Obviously, healthcare workers can’t control which patients come through the doors of their facilities. They can, however, have a strategy in place for preventing violence and effectively halting it when it does happen.

Defining violence in the workplace

The CSPS defines workplace violence and its elements in its Statement on Violence in the Workplace1:

waiting rooms, among others.1 Violence is also more likely to erupt when facilities are understaffed, especially during meal times and visiting hours.1

Intimidation includes, but is not limited to, stalking or engaging in actions intended to frighten and coerce.

Healthcare workers are also more likely to encounter violence when they work alone or directly with volatile people, especially if those people are under the influence of drugs or alcohol, have a history of violent behavior or have been diagnosed with certain psychiatric conditions.1

Physical attack is unwanted or hostile physical contact such as hitting, fighting, pushing, shoving or throwing objects.

Obviously, healthcare workers canʼt control which patients come through the doors of their facilities. They can, however, have a strategy in place for preventing violence and effectively halting it when it does happen.

Workplace violence includes, but is not limited to, intimidation, threats, physical attack, property damage and sexual harassment.

Threat is the expression of intent to cause physical or mental harm.

Property damage is intentional damage to property.

Sexual harassment is unwelcome advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature, when submission to or rejection of this conduct explicitly or implicitly affects a person's employment or education, unreasonably interferes with a person's work or educational performance or creates an intimidating, hostile or offensive working or learning environment.

Triggers for violence in the healthcare workplace

Many patients who are treated in hospitals and other care facilities are at an increased risk of exhibiting violent behavior. Medical conditions associated with violent tendencies include hypoglycemia, electrolyte imbalance, anemia, hypoxia, alcohol intoxication, pain, dementia and the use of codeine, PCP, LSD and other drugs.3 However, while these factors might make a person more likely to behave in a violent manner, the individualʼs tendency toward violence must still be triggered in some way.4 These triggers are referred to as “situational factors.”4 There are a number of situational factors present in hospitals that can contribute to violent behavior. These include poor environmental design, inadequate security, access to firearms, poorly lit areas and overcrowded, uncomfortable

What can be done?

The U.S. Occupational Safety and Health Administration (OSHA) lists the following as the five key components in the prevention of workplace violence2:

Management commitment and employee involvement Management and frontline employees must work together as a team or committee for a violence-prevention program to be successful. Management must show concern for employee safety and allocate appropriate resources. Employees must comply with the workplace violence prevention program and report violent incidents promptly and accurately.

Worksite analysis A worksite analysis is a commonsense look at the workplace to find existing or potential hazards for workplace violence. A threat assessment team, patient assault team or similar task force or coordinator can assess the vulnerability of the workplace and determine the appropriate actions to be taken. Hazard prevention and control After hazards are identified through the worksite analysis, design measures should be taken (whether through engineering or administrative and work practices) to prevent and control these hazards.

Aligning practice with policy to improve patient care 55

Safety and health training Training and education for both managers and employees can ensure that all staff members are aware of potential security hazards and how to protect themselves and their coworkers. Security personnel will also need their own specific training.

Recordkeeping and program evaluation Recordkeeping is crucial in tracking the effectiveness of a violence prevention program. Examples of records and documents include the OSHA Log of Work-Related Injury and Illness (OSHA Form 300); medical reports of work injury and supervisorsʼ reports for each recorded assault; records of incidents of abuse, verbal attacks or aggressive behavior that might be threatening, information on patients with a history of past violence, drug abuse or criminal activity; documentation of minutes from safety meetings and records of all training program, attendees and qualifications of trainers. Employers who would like to learn more about implementing an appropriate workplace violence prevention program are encouraged to contact the OSHA Consultation Service at (800) 321-OSHA. You can also learn more at References 1 Council on Surgical & Perioperative Safety. Statement on Violence in the Workplace. Available at: Accessed June 19, 2008. 2 U.S. Department of Labor. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Available at: Accessed June 19, 2008. 3 Carroll V. Preventing violence in the healthcare workplace. Alabama Nurse. 2004 Mar-May.

Joint Commission Targets Bullying On July 9, 2008, The Joint Commission called for a crackdown on bullying among healthcare professionals, noting that such behavior poses a serious threat to patient safety and the overall quality of care.

In a press release titled “Joint Commission Alert: Stop Bad Behavior among Health Care Professionals,” the group announced it will be introducing new standards requiring more than 15,0000 accredited healthcare organizations to create a code of conduct that defines acceptable and unacceptable behaviors. These organizations will also need to establish a formal process for managing unacceptable behavior.

The Joint Commission is recommending that healthcare organizations take 11 specific steps to help put an end to

If you’re a victim

The Massachusetts Nurses Association (MNA) has compiled a list titled “Ten Actions a Nurse Should Take If Assaulted At Work.” Those ten actions are5: • Get help and get to a safe area • Call 911 for police assistance • Get relieved of your assignment • Get medical attention • Exercise your civil rights, which might include filing charges with police • Report the assault to your supervisor • Report the assault to your union representative • Get counseling or assistance for Critical Incident Stress Debriefing (CISD) to prevent post-trauma symptoms • Get copies of all reports and keep a diary of events • Return to work only when you feel safe and supported

4 Cooper C, Swanson N. Workplace violence in the health sector: state of the art. Geneva, Switzerland: International Labour Office, 2002. Available at: Accessed June 19, 2008. 5 Massachusetts Nursing Association. Ten Actions A Nurse Should Take If Assaulted at Work. Available at: Accessed June 19, 2008.

bullying among physicians, pharmacists, therapists, support staff and administrators. Among those 11 steps: • Educate all healthcare team members about professional behavior • Hold all team members accountable for modeling desirable behaviors, and enforce the code of conduct consistently and equitably • Establish a comprehensive approach to addressing intimidating and disruptive behaviors • Determine how and when disciplinary actions should begin • Develop a system to detect and receive reports of unprofessional behavior, and use non-confrontational interaction strategies to address intimidating and disruptive behaviors

To view the press release in its entirety, please visit

56 The OR Connection

When one thinks of the operating room, phrases like “cutting-edge technology,” “the future of medicine” and “the newest procedures” come to mind. Although this is true, comments like “This is how we have always done it” and “What? Something new to learn?” are often heard as well. While these barriers are hard to overcome, the OR of the future has many champions, including Callie Craig, Team Manager and Perioperative Clinical Educator at INTEGRIS Baptist Medical Center in Oklahoma City, Oklahoma.

Callie Craig: A Nurse Hero By Megan Giovinco, RN, CNOR, RNFA

Callieʼs passion for perioperative nursing has been evident throughout her eight-year tenure in surgery. She is very involved in her facility as a member of numerous committees and councils and was named INTEGRIS Surgery Department Nurse of the Year in 2002.

Recruitment is one of Callieʼs primary concerns. Along with serving as the co-chair of the Integris Nurse Recruitment and Retention Team, she works with her facility in a variety of ways to bring in new perioperative professionals. Callie is proud to be a part of the many creative ways that INTEGRIS supports both novice and experienced nurses. As the departmentʼs educator, Callie has a great deal of involvement with “next generation” nurses and works to

58 The OR Connection

Special Feature

Callie feels that the future of the OR depends on all generations of perioperative professionals working together and learning from each other.

advocate the value they bring to the surgical arena. It was for these efforts that she was the recipient of AORNʼs Next Generation Achievement Award at the 55th Congress in Anaheim earlier this year. She was also elected to AORNʼs National Nominating Committee, for which she pledges to “bring my passion for perioperative nursing and the success of [AORN].” Her passions include not only recruitment but the promotion of overall workplace safety, encouraging nurses to act as patient and professional advocates and ensuring the continued growth of AORN. Callie is certainly no new face to AORN. As a member of the Central Oklahoma Chapter of AORN since 2003, she has attended Congress five times, three times as a delegate. She is also a member of the Educator/Clinical Nurse Specialist and Leadership Specialty Assemblies. She has served as both president and vice president of her local chapter and as a part of the membership and nominating committees. She is also active in the Oklahoma State Council of Perioperative Nurses and has served as their president. Throughout her career, Callie has sought to improve her practice by continuing her education. She received her Certification for Professional Achievement in Perioperative Nursing (CNOR) and earned her BSN from the University Of Arkansas Eleanor Mann School Of Nursing. Recently, she received her masterʼs degree in Nursing Administration from the University of Oklahoma Health Science Center.

Even though Callie is seen as an advocate for the next generation, she strongly believes that the “current generation” that makes up part of the perioperative team has a great deal to offer. Their experience and knowledge is invaluable to the staff they work with and the patients for which they care. Callie feels

that it is just as important to retain these perioperative professionals as it is to recruit new ones.

Callie feels that the future of the OR depends on all generations of perioperative professionals working together and learning from each other: “The new nurses and techs bring the knowledge of their recent education and the seasoned nurses have so much experience to share. They need to get to know each other.” Callie encourages mentoring as a way for staff to learn from each other. She credits her achievements to the support and coaching she received from her own mentor, Janet Lewis, RN, MA, CNOR, the Administrative Director of Surgical Services at INTEGRIS Baptist Medical Center. As a mentor to Callie, Janetʼs own passion for surgery was infectious. “She always said ʻcome with me – I will show you how,ʼ” Callie recalls.

Callieʼs passion for education and helping others spills over into other aspects of her life as well. She is a leader of Precept Upon Precept Bible Study. She is also a member of the Council Road Baptist Church Womenʼs Council. She continues to help the next generation as a community volunteer for the Junior League of Oklahoma City. Callie has been known to quote Karen Kaiser Clark, who once said, “Life is change. Growth is optional. Choose wisely.” Callie has certainly chosen to grow with the changes of her profession. She believes that the opportunities are infinite in todayʼs healthcare environment. She feels that the perioperative professionalʼs reputation as the authority for patient and staff safety must continue to expand as the challenges facing the medical community as a whole are addressed. Humbly, Callie hopes that she can be an example to other young nurses. There is no question that she is not only an example but also an inspiration to all perioperative professionals.

Aligning practice with policy to improve patient care 59

S.T.O.P. for Safety.

It could be the difference between life and death. Wrong site surgery has recently moved into the number one position as the most frequently reported hospital error.1 This is despite a conscientious effort to eliminate this problem before it occurs. What is needed is another layer of safety...something that will improve our chances of correcting the mistake before it happens.

If you would like to receive a free sample of the S.T.O.P. Drape system to evaluate for yourself, ask your Medline representative or call us at 1-800-MEDLINE. STOP!!! S TOP!!! Perform P erform “TIME “TIME O OUT” UT” Verify V erify ccorrect: orrect: Person Person Procedure P rocedure Site S ite & Side S ide Date: D ate: _______ _____ Time: Time: ______ ______ Surgeon’s S urgeon’s Initials: Initials: ______ ____

Enter S.T.O.P. Surgical Drapes from Medline. We just made a good idea even better. S.T.O.P. (Surgical Time Out Procedure Drape) are available in a variety of configurations, and include a “S.T.O.P.” strip* across the fenestration. As a result, you can’t forget to take a time out to verify the correct patient, procedure, side and site. Then all that is left is to hand the sticker off to the circulating nurse to include in the medical record, documenting that the verification process was completed.

S.T.O.P. strip and sticker

References 1 The Joint Commission. The Statistics page. Available at: Accessed March 13, 2008.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Caring for Yourself

By Brian Tracy

The greatest obstacle to success

The most common trap

with not making a mistake, with seeking for security above all

“I canʼt,” but “I have to,” “I have to,” but “I canʼt.”

The fear of failure is the single greatest obstacle to success in

adult life. Taken to its extreme, we become totally preoccupied

other considerations. The experience of the fear of failure is in the words of “I canʼt,” “I canʼt.” We feel it in the front of the body, starting at the solar plexus and moving up to the rapid beating of the heart, rapid breathing and a tight throat. We also experience

this fear in the bladder and in the irresistible need to run to the bathroom.

The fear of rejection holds you back

The second major fear that interferes with performance and

inhibits expression is the fear of rejection. We learn this when our parents make their love conditional upon our behavior. If we do what pleases them, they give us love and approval. If we do some-

thing they donʼt like, they withdraw their love and approval – which we interpret as rejection.

The roots of a Type A behavior

As adults, people raised with conditional love become preoc-

cupied with the opinions of others. Many men develop Type

A behavior that is characterized by hostility, suspicion and an obsession with performance to some undetermined high standard. This is expressed in the attitude of “I have to,”

More than 99 percent of adults experience both these fears of failure and rejection. They are caught in the trap of feeling,

The key to peak performance

The antidote to these fears is the development of courage, character and self-esteem. The opposite of fear is actually love,

self-love and self-respect. Acting with courage in a fearful situation is simply a technique that boosts our regard for ourselves to

such a degree that our fears subside and lose their ability to affect our behavior and our decisions.

Action exercises

Here are two things you can do to increase your self-esteem and self-confidence and overcome your fears.

First, realize and accept that you can do anything you put your

mind to. Repeat the words, “I can do it! I can do it!” whenever you feel afraid for any reason.

Second, continually think of yourself as a valuable and important

person and remember that temporary failure is the way you learn how to succeed.

Reprinted with permission from

“I have to,” and is associated with the feeling that “I have to work harder and accomplish more in order to please the boss” who has become a surrogate parent.

Aligning practice with policy to improve patient care 61

How to Thrive in a Tough Economy

Unless you are on another planet, it is likely that your organization has already gone through several “downsizings” or “rightsizings,” as your boss might like to call them. Time to get depressed, right? Wrong!

62 The OR Connection

By Wolf J. Rinke, PhD, RD, CSP

Special Feature

and financial officer would fit into this category. Next are the project managers. They are responsible for making sure that the talent and resources are organized in such a way that the project gets done. Next is the talent. These are the people who have the skills to get the job done, such as nurses, OR techs and other front-line healthcare professionals. To thrive in this tough economy, it is important that you master “winning management” skills so that you can perform equally well in the project manager or resource provider role. (For details read my Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations book.)

Think global

Time to put yourself in the driverʼs seat of your career by developing new skills that will enable you to take advantage of the opportunities that are unfolding before your very eyes – opportunities that will enable you to not only survive, but thrive in this tough economy.

Think projects

Old organizations were organized by departments and position titles. Today, projects accomplish most work. To thrive in a project environment, recognize that work gets done primarily by three distinct specialties. First, there are the resource providers. These are the folks who develop and supply talent or money. Your human resource manager

Globalization is accelerating at a nanosecond pace. To take advantage of globalization, you must dramatically increase your cultural awareness. If you are now employed in a primarily “homogeneous” organization and are not at least 90 percent satisfied, seek employment in a multicultural organization. Donʼt know where to start? Get a copy of Fortuneʼs latest issue of either 100 Best Companies to Work For (typically published in February) or Americaʼs Most Admired Companies (typically issued in March of every year) and apply to any of the companies listed. Want to stay in health care? Not a problem, there are many on either list. For example, Methodist Hospital System is in the number 10 spot on the 2008 100 Best Companies to Work For and Manor Care is in the number one spot for the Healthcare Medical Facilities Group in the 2008 Americaʼs Most Admired Companies.

Equally important, learn a foreign language. If youʼre not fluent in at least one foreign language, you will be in trouble

Aligning practice with policy to improve patient care 63


you can simply no longer expect to be Think of yourself real soon. And put your language to work by traveling to a country compensated for time, only for results as self-employed that speaks the language of inSeeing yourself working for and problems solved. terest to you. Youʼll really learn to one company for the rest of speak it, become culturally senyour career is, to say it gently, sitive whether you want to or not crazy! Itʼs just not going to and will bring back a ton of great ideas to accelerate your happen! In this tough economy, itʼs important that you see success curve dramatically. yourself as “self-employed,” or “renting” your services out Become an effective team player and leader

Like it or not, teams are the way lots of work is being accomplished in todayʼs organizations. Being effective in this environment requires that you learn how to empower others and master leadership and winning management skills, and be equally comfortable and effective in a supportive role as in a leadership role. (For more, read my Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness book.)

Focus on delivering exceptional quality service

Delivering exceptional quality service is not an option, but rather a survival strategy. We must be absolutely clear about who provides us with our paycheck. No, itʼs not your boss or even your organization. It is the person you serve – an external or internal “customer.” As a litmus test of how customer-focused you are, look back at your calendar for the last week to find our how much actual time youʼve spent with your external or internal customers. If you are not spending at least one third of your time with your “customers,” you are messing up.

Become a problem solver

One of the best ways to position yourself for advancement or pay increases is to become a problem solver. In this tough economy, you can simply no longer expect to be compensated for time, only for results and problems solved. So actively look for a problem that impacts negatively on the bottom line then put a team together and solve it. Then, let others know (especially the powers-that-be) what a great job your team did and how much your team improved the profitability of your organization. If you do that consistently, you will be ready to be promoted or negotiate for an increase in pay. (If youʼd like help with that, devour my Win-Win Negotiation CPE program.)

64 The OR Connection

to someone else (your employer). To get started, pretend that you are an entrepreneur or a consultant who is selling services to a client (your employer). To make this realistic, compute your daily compensation. Be sure to add about 30 percent for benefits. Then get in the habit of asking yourself “Have I created value today that exceeded my daily compensation?” Repeat that question every day you are at work. You may even find it helpful to place a nice-looking sign on your work station that asks “How are you creating $_____ of value today?”

The other side of the coin is to keep asking “How have I ʻgrownʼ in my job today?” To make this happen, think of going to work each day with a “briefcase” of skills and competencies. At the end of the day, check your briefcase to see if there is more in it than at the beginning of the day. If, day after day, what you bring to work is the same as what you take home, itʼs is time to move on to a more challenging “assignment.”

Get in the habit of asking yourself, “Have I created value today that exceeded my daily compensation?” Become an expert networker

One of the most powerful skills you can develop is to become a highly effective networker, both inside and outside of your organization. When it comes time to find a new assignment, your network, more than anything else, will determine how fast youʼll find your next dream job. To test your networking effectiveness, ask yourself who you have been eating lunch with during the past week. If it is pretty much the same people, you are missing tremendous networking opportunities. Get in the habit of eating lunch with

different people three out of five days a week, to sit with people you donʼt know at meetings and to attend conferences that are sponsored by groups other than yours.

Check yourself

To assess how well you are achieving a competitive advantage in this tough economy, ask yourself the following diagnostic questions: Am I learning? If you are not constantly learning new things, your value in the marketplace is diminishing rapidly.

Am I being taken advantage of? Your employer is taking advantage of you if you consistently sacrifice your long-term development to put out short-term “fires.” Donʼt let your ego get the better of you when you are being told that you are so critical to the organization that “we canʼt do without you.” Hogwash! No one is indispensable. Never, ever get caught in persistent short-term traps at the expense of your long-term development. If my job was open today, would I get it? Itʼs important that you “benchmark” your skills all of the time.

ASK YOURSELF... • Am I learning? • Am I being taken advantage of? • If my job was open today, would I get it? • Am I adding value? • Am I good at selling? • Am I energized by change? • Does my résumé focus on contributions?

Continued on Page 36

Aligning practice with policy to improve patient care 65

Small in size. Big on safety.

Sometimes smaller is better! At just 15 square inches, the Medline Universal Pad with proprietary Safety Ring meets the same thermal performance standard as traditional electrosurgical pads up to 33% larger in conductive surface area. Despite its smaller size, this pad is big on safety. The proprietary Safety Ring allows the pad to be oriented in any direction and also reduces corner and edge effect by more uniformly dis-

The transthermal backing on 9100 Series electrosurgical pads provides a barrier of moisture; it is waterproof and fluid resistant. The backing allows heat to escape 25% faster than the foam traditionally used on grounding pads, reducing the risk of excessive heat buildup.

For more information on the impact the Universal Pad 9100 Series can have in your OR, contact your Medline sales representative or call 1-800-MEDLINE.

persing electrosurgical current over the entire conductive surface of the pad. Electrosurgical Pad 9100 Series

Manufactured by 3M Medical Division Š2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

One way to do that is to look at the want ads to find out what the marketplace is looking for. If you do not possess the skills that the marketplace is looking for, itʼs time to invest more in yourself.

Am I adding value? How long does it take you to answer this question? If you are unable to answer it immediately, in fewer than two or three sentences, you can assume that no one else knows how you contribute value either. In that case, you are a likely target during the next downsizing.

Am I good at selling? Many healthcare professionals see no need to become excellent at selling. The reality is that you sell all the time. You sell your patient on getting better, you sell your boss on a raise and you sell your team members on an idea. In addition, you do the same at home with your spouse, children and even your pets. Since it is something you do all of the time, I recommend that you get good at it. No, wait, I recommend you get great at it! So start looking for a quality sales program and attend it this year! Am I energized by change? If you are still fighting or resisting change, you are in trouble. All indications are that change will continue to accelerate at “hyper speed,” so you might as well start welcoming it.

Does my résumé focus on contributions? Finally, to check how focused you are on contributions, get out your résumé and check for specific outcomes, specific impact on the organization and variety and content of work, projects and leadership experiences. Are you impressed? Would you hire this person? If so, congratulations!

liberate and empower you. Action will get you to grow, change and adapt. Action will provide you with virtual job security, will enable you to achieve the competitive advantage and assure that you thrive in this tough economy.

About the author

Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar leader, management consultant, executive coach and editor of the free electronic newsletters Make It a Winning Life and The Winning Manager. To subscribe, go to He is the author of numerous books, CDs and DVDs including Winning Management: 6 Fail-Safe Strategies for Building High-Performance Organizations and Donʼt Oil the Squeaky Wheel and 19 Other Contrarian Ways to Improve Your Leadership Effectiveness, available at His company also produces a wide variety of quality pre-approved continuing professional education (CPE) self-study courses available at www.easy Reach him at

The most important concept of all time: Take action

There is one more skill that you need to master. This one is more important than all the others. Itʼs the one skill that, when all else fails, will determine whether you will thrive in this tough economy. The skill is to take action! Action lets you know whether what youʼve tried works. If it does, do more of it. If it does not, try something else and start the same process all over again. Soon youʼll find yourself succeeding faster than you have ever thought possible. And whatever you do, avoid fretting about having failed – there is no such thing, unless you make the same mistake over and over again. Action gets you away from bemoaning change and mourning the lack of job security. Action will

Aligning practice with policy to improve patient care 67

Special Feature

Angel’s Passion for Pink By Laura Kuhn The OR Connection staff writer

Angel hummed to herself as she tacked a poster on the hospitalʼs bulletin board. She heard footsteps approaching and turned to see her coworker Mary peering over her shoulder at the poster. “Whatʼs that, Angel?” Mary asked. “Itʼs pretty. I like the pink ribbons. They match the ribbon on your lab coat!”

“Iʼm hosting a meeting for staff members to remind them how important it is to conduct monthly breast self-exams,” Angel explained. “Can I count on you to be there?”

“You bet!” Mary replied. “Iʼll even bring some cookies.” She headed off down the hall to visit her next patient. Angel smiled as she smoothed out the corners of the poster. She was known for tirelessly campaigning for breast cancer education, but very few people knew what had drawn her to

68 The OR Connection

the cause. She planned to reveal that at the meeting the next day. Thanks to Angelʼs posters and word of mouth, the meeting room was filled to capacity. True to her word, Mary arrived bearing a tray of cookies. At the podium in the front of the room, Angel was nervously shuffling a stack of note cards. She had written down what she planned to say, but as her coworkers took their seats and started looking expectantly at her, she decided to place her notes in her pocket and simply speak from her heart. “Hi, Iʼm Angel, and I know most of you,” she said. “You might have noticed that I spend a lot of time promoting education about breast cancer, and encouraging you to do monthly selfexams. What you might not know is why I care so much.” She took a deep breath and steadied her voice.

“When I was a sophomore in college, my mother was diagnosed with breast cancer. I spent the next six months, what were ultimately the last six months of my motherʼs life, at her side. I was there when she was wheeled out of surgery after a double mastectomy. I was there when chemo caused her beautiful hair to fall out all over her pillow. And I was there when she admitted to her doctor that she had never done a breast self-exam.

“My mother didnʼt know how to perform a self-exam, and she wasnʼt comfortable with the idea. She didnʼt know that there could be outward signs of breast cancer, such as change in the size or shape of the nipple. She didnʼt know that dimpling or puckering could be signs of an underlying problem. “My mom didnʼt know these things, just as a lot of people donʼt understand the full scope of how serious a problem breast cancer still is. Weʼre making advances in early detection and treatment, but this disease is by no means going away. In fact, more than 1.1 million women throughout the world will be diagnosed with breast cancer this year, and more than 410,000 of those women will die.”

Angel looked around the room and saw that the faces of many audience members had turned grim. She needed to inspire them, and fast!

“But thereʼs good news, too,” she continued. “Today, someone who is diagnosed with breast cancer in its earliest stages has a 98 percent chance of living. That rate was only 77 percent in 1982. And education is helping to emphasize the importance of screening, early education and the need for more research.” Angel grabbed for the stack of pamphlets she had brought with her and began to hand them out. “These tell you how to perform a breast self-exam and give you more information on ways you can help spread the word,” she said. “Please, take a bunch of them! Give them to your friends, your family, your patients.” She was encouraged to see that the members of the audience were taking four or fivepamphlets as they were passed along.

She made her way back up to the front of the room to finish speaking. “Thank you so much for coming to this meeting. I lost my mother to breast cancer, and Iʼll miss her every day of my life. With your help, though, we can prevent someone else from experiencing that same agony. Education is truly the key. Together, we can save lives through early detection.” Angel smiled and was thrilled to see smiling faces looking back at her.

Stay tuned for the continued adventures of Medline’s family of nurse dolls, Angel, Aurora, Anastasia, Ami and Alice!





Aligning practice with policy to improve patient care 69

The choice is yours Medline’s comprehensive line of facemasks was designed to meet a variety of needs and preferences, but all of our masks are united by a common trait— quality. Every mask we manufacture—from our fluidresistant masks to our spearmint-scented masks—is backed by Medline’s quality guarantee and designed to exceed expectations for comfort and protection. • Fluid resistant • Fog free • Spearmint scented • Chamber style • Isolation • Procedure • Face shield • Protective eyewear

For more information on Medline facemasks, please contact your Medline sales representative or call 1-800-MEDLINE.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Caring for Yourself

Medline Supports Breast Cancer Awareness 365 Days a Year Together We Can Save Lives Through Early Detection Breast Cancer Campaign Every three minutes a woman in the United States is diagnosed with breast cancer. The chance of developing invasive breast cancer at some time in a woman's life is about 1 in 8.¹ These are startling statistics, but behind these numbers are people — sisters, daughters, mothers, grandmothers, neighbors and friends. Any one of the 182,460 women who will be diagnosed with invasive breast cancer this year could be someone we love. Although mammograms are among the best forms of early detection, more than 13 million American women over the age of 40 have never had one.2 The Centers for Disease Control recommend that women begin having yearly mammograms at age 40.

These facts form the foundation of Medlineʼs “Together We Can Save Lives through Early Detection” campaign. Medline is on a mission to change the future by taking action now. 2008 marks the third year that Medline has partnered with the National Breast Cancer Foundation (NBCF), which provides grants to hospitals and healthcare organizations that offer free mammograms for underprivileged women. To date, Medline has donated $350,000 to the NBCF to give back to customers and their communities, help promote early detection of breast cancer and ultimately save lives.

Spreading the word

To keep early detection on everyoneʼs minds, Medline sponsors a number of outreach projects throughout the year and distributes several products and programs to promote awareness.

AORN breakfast forum

In March, Medline hosted a breakfast forum for 900 perioperative nurses at the annual meeting of the Association of periOperative Registered Nurses (AORN) in Anaheim, Calif. Featured speaker, Dr. Marla Shapiro, author of Life in the Balance: My Journey with Breast Cancer and renowned Canadian on-air medical expert, delivered a dynamic presentation on coping with stress, balancing life and battling breast cancer. Visit to learn more about the event.

Beyond the Shock® DVD

Medline, in partnership with the NBCF, distributes free copies of the DVD “Beyond the Shock,” a step-by-step guide to understanding the diagnosis of breast cancer. More than 70 leading oncologists contributed to the content. To request a copy, contact Jennifer Freedman at (847) 643-4358 or

Angel doll

Angel, the second-born in Medlineʼs family of nurse dolls, promotes infection prevention and she also sports pink scrubs and a pink ribbon to support breast cancer awareness. The Angel doll is distributed by Medline at trade shows and large customer events.

Pink ribbon products

Medline sells several pink ribbon products, including a Breast Cancer Awareness Rollator and bath bench, a pink ribbon lab coat and special scrubs available on A customerʼs purchase of these products supports Medlineʼs partnership with the NBCF. Visit or or contact your Medline sales representative for more information. For more information on Medlineʼs breast cancer awareness campaign, visit or contact Jennifer Freedman at 847-643-4358 or

References: 1. American Cancer Society. Cancer Reference Information. “What Are the Key Statistics for Breast Cancer?” Available at: CRI/content/CRI_2_4_ 1X_What_are_the_key_statistics_for_breast_cancer_ 5.asp. Accessed July 15, 2008. 2. The Breast Cancer Site. About Breast Cancer page. Available at: =2&link=ctg_bcs_aboutbreastcancer_from_home_maincolumn.

Aligning practice with policy to improve patient care 71

Caring for Yourself

Ease the Discomfort of PMS You're feeling bloated and irritable all at the same time. Sound familiar? You're probably having premenstrual syndrome (PMS). Up to 85 percent of menstruating women have at least one PMS symptom as part of their monthly cycle, according to the American College of Obstetrics and Gynecologists. The emotional and physical symptoms, which usually occur in the week or two before your period, can range from mild to severe. Symptoms vary from person to person and may include: • • • • • • • • • • •

Irritability or mood swings Tension or anxiety Acne Breast swelling and tenderness Tiredness Insomnia Bloating Depression Digestive problems Headaches Joint or muscle pain

Often, symptoms go away after your period starts.

Try these tips

If you think you have PMS but want to find out for sure, keep track of your symptoms on a calendar for a couple of months. Note their severity and the date your period starts. Then, show your doctor the calendar and your notes.

The cause of PMS remains unclear, but you may be able to ease symptoms by following these self-care tips from the U.S. Department of Health and Human Services: • Take a daily multivitamin with 400 micrograms of folic acid and a calcium supplement with vitamin D. • Exercise regularly. For safety's sake, first check with your doctor. • Eat a healthful diet that includes plenty of fruits, vegetables and whole grains. • Avoid salt, sugary foods, caffeine and alcohol. • Try to get eight hours of sleep every night. • Don't smoke.

Lifestyle changes alone may not bring relief if you have severe symptoms. If this is the case, your doctor may suggest an over-the-counter pain reliever or other medicines. Reprinted with permission from United Healthcare

72 The OR Connection

Healthy Eating

Holy Guacamole! You can make this avocado salad smooth or chunky depending on your preference. Nutritional Information Servings Per Recipe: 4 Amount Per Serving Calories: 264 Total Fat: 23.3g Cholesterol: 0mg Sodium: 601mg Total Carbs: 16.4g Dietary Fiber: 8.8g Protein: 3.7g

Guacamole (4 servings) Prep time 10 minutes Ready in 10 minutes

3 avocados - peeled, pitted and mashed 1 lime, juiced 1 teaspoon salt 1/2 cup diced onion 3 tablespoons chopped fresh cilantro 2 roma (plum) tomatoes, diced 1 teaspoon minced garlic 1 pinch ground cayenne pepper (optional)

In a medium bowl, mash together the avocados, lime juice and salt. Mix in onion, cilantro, tomatoes and garlic. Stir in cayenne pepper. Refrigerate 1 hour for best flavor, or serve immediately.


Aligning practice with policy to improve patient care 73

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For your free cost-savings analysis, contact your sales representative or call 1-800-MEDLINE.

* Patent pending ©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.


The following pages contain practical tools for implementing patient-focused care practices at your facility. Electrosurgery Electrosurgery Checklist..............................76 Electrosurgical Cautery Safety Policy and Procedure ..................................78 Pressure Ulcer Prevention Policy and Procedure ..................................81 Patient Safety

Surgical Safety Checklist........................86

Employee Safety

Management/Employee Checklist ..........89

Employee Incident Report ......................90 Aligning practice with policy to improve patient care 75

Forms & Tools

Electrosurgery Checklist 1

Electrosurgery Checklist

Preoperative Precautions and Procedures

Physical Condition

 Examine the ESU and its accessories for defects— do not use cables or accessories with damaged (cracked, burned, or taped) insulation or connectors.  Confirm that the ESU has been inspected for safety and performance by a qualified BMET or clinical engineer and that the next inspection is not yet due.

Return Electrode Contact Quality Monitor (RECQM) or Cable Continuity Alarm

 Check the operation of the RECQM or the return electrode cable continuity alarm by attempting to operate the unit with the dispersive electrode disconnected—the unit should not activate, and a tone should sound.

Audible Activation Indicator

 Activate the unit using each footswitch and handswitch, and verify that the audible activation tone is loud enough to be heard over other noises in the OR.  Verify operation of any other alarms or protective features.

Safety Holster

 Position a safety holster for the active electrode in a convenient location.

Dispersive Electrode

 Use a full-surface adhesive electrode.  Inspect the electrode before placement for any flaws or damage (e.g., discoloration, insufficient amounts of conductive adhesive).  Confirm that the electrode's expiration date has not passed.  Clean, shave, and dry the application site.  Follow the manufacturer's recommendations for application, and ensure firm contact of the electrode with the skin.  Do not apply the electrode to areas where pressure is applied to the patient (e.g., underneath the patient).

76 The OR Connection

 Do not overlap sections of the electrode (e.g., when applying around a small limb).  When possible, place a long edge of the electrode closest to the surgical site.  If possible, do not place the dispersive electrode (or active electrode) cables near internal pacemaker leads.

Alternate Sites

 Eliminate patient contact with grounded objects whenever possible.  If possible, remove nonvital monitoring electrodes (e.g., esophageal and rectal probes).  Keep ECG and other monitoring electrodes as far as possible from the surgical site and the active and dispersive electrode cables.  Do not use needles as monitoring electrodes (these increase the risk of alternate site burns due to higher current density at the electrode site).

Prepping Agents

 Avoid using flammable prepping agents or other flammable fluids (e.g., acetone degreaser).  Avoid accumulating pools of fluids, especially near patient electrodes.

Sparking the Active Electrode

 Do not spark the active electrode to ground or to the dispersive electrode to test the ESU.

Intraoperative Precautions and Procedures

 Minimize buildup of O2 and N2O beneath drapes and in the oropharynx.  Activate the unit after vapors from flammable prepping solutions and tinctures (if used) have dissipated.  Activate the unit only when ready to deliver electrosurgical current and only when the active tip is in view; avoid prolonged activation.  Use the lowest effective ESU output setting; do not continue to increase power settings if you aren't getting results—look for other problems (e.g., confirm adequate placement of the dispersive electrode, check all cable connections).

Electrosurgery Checklist 1

 Check contact and adherence of the dispersive electrode each time the patient is repositioned.  Always place the active electrode in a safety holster when not in use.  Allow only the user of the active electrode to activate the handswitch or footswitch.  Do not use two active electrodes on ESUs that produce simultaneous activation of both electrodes when only one switch is activated.  Document every procedure in the OR record; include the ESU identification number, ESU settings used (monopolar cutting and coagulation, bipolar), location of the dispersive electrode, and the condition of the skin at the dispersive electrode site before and after the procedure.  Document use and position of any other equipment (including identification numbers) used during the procedure (e.g., hypo-/hyperthermia unit, temperature probes).

Postoperative Precautions and Procedures

 Inspect the patient for injuries at the dispersive electrode and other sites (e.g., the sacral area— electrosurgical injuries typically appear immediately following the procedure; pressure injuries may not show up for as long as one or two days following surgery).  Document all findings.  If any problems are noted during or after the procedure, save all disposable items and their packages (so that expiration dates can be confirmed). Courtesy of Medical Device Safety Report (MDSR) ECRI Institute, 2008.

Forms & Tools

Regarding “Checklists...” Worldwide, the WHO aims to have the checklist operating in 2,500 hospitals in the most populous countries (with 75 per cent of the world's population) by the end of next year.

Since the 1930s, airplane pilots have run through checklists before taking off. Now the World Health Organization wants surgeons all over the globe to use them, too.

Dr. E. Patchen Dellinger, a surgeon at the University of Washington Medical Center in Seattle, says people are surprised when he tells them about the project. "One of the common reactions is, 'You mean you weren't doing that before? Good heavens!'" he says.

Gawande says there's been some resistance to the list. One London surgeon thought it was demeaning "Mickey Mouse stuff" until one day in the operating room. "Right before the incision [the medical team] took a timeout," Gawande says, "and when it came to the nurse's turn to raise any concerns, the nurse asked: 'Are we really sure we have the right size knee replacement for this patient?'" Turns out, they didn't — not anywhere in the hospital. That surgeon now swears by the surgical checklist.

Aligning practice with policy to improve patient care 77

Forms & Tools

Policy and Procedure

Electrosurgical Cautery Safety


To provide for the safe operation of electrosurgical units, used for the purpose of cutting and coagulation of body tissue with a high frequency electrical current during surgical procedures.


 Electrosurgical Generator  Electrosurgical Grounding Pad  Electrosurgical Active Electrode (Pencil)


 All electrosurgical generators shall meet the performance and safety standards of the hospital. – All electrosurgical units must be approved by the hospital Biomed. – Only electrosurgical units which are UL approved shall be used in the operating room. – Surgical Services personnel are provided with detailed instructions from the electrosurgical unit's manufacturer. Operational directions are attached to each electrosurgical unit. – Surgical Services personnel are evaluated annually on the safe competency form use of the electrosurgical unit and its components. – The electrosurgical unit generator is inspected yearly by the hospital Biomed. Dates of inspection are posted on units. Each electrosurgical unit generator is assigned an ID number. – The electrosurgical unit is properly grounded, mounted on a stand, easily cleaned and movable. – The electrosurgical unit generator shall be kept clean and protected from spills. – The electrosurgical unit footswitch shall be designed for easy cleaning, shall be shock-resistant and designed to minimize unintentional activation. – The electrosurgical unit footswitch cord shall be long enough to reach the user without stress. – Before each use, the electrical cord, connections, plug and foot switch cord shall be inspected for damage. The unit shall be removed from service if damaged. – Before each use, the electrosurgical unit safety features (lights, activation sound, etc.) shall be tested. – Power settings for coagulation and/or cutting shall be as low as possible for each procedure, confirmed orally with the surgeon before activation and determined according to manufacturer recommendation. Activation tones are not to be turned off or adjusted to a lower setting. (The activation tone on newer models cannot be turned off or adjusted.)

78 The OR Connection

– Before each electrosurgical unit use, the operative field shall be inspected for alternate ground points. Personnel and/or patients may be injured, if the current does not follow the designated path. Isolated patient EKG lead units shall be used. The patient shall not be in contact with metal table parts. – The patient's skin integrity shall be evaluated before and after electrosurgical use. Particular areas to observe are under the electrode, under EKG leads, temperature probe entry sites and positional pressure points. – The dispersive electrode, cord and pad, and the active electrode and cord shall be retained for use during the investigation of an adverse post-op skin reaction.

 The Electrosurgical Ground Pad (Dispersive Electrode): – Only disposable dispersive electrodes evaluated by the hospital Biomedical Engineer, are to be used in the Surgical Services Department. – The dispersive electrode shall be inspected before each use for wire breakage or fraying. All connections shall be intact and clean. – The dispersive electrode shall be long enough and flexible enough to be placed on the patient without stress on any connection. – The dispersive electrode cord shall fasten directly into a labeled, stress-resistant receptacle on the electrosurgical unit. – The dispersive electrode pad shall be placed on the patient, on clean dry skin over a large muscle mass, as close to the operative site as possible. Bony prominences, hairy surfaces, and scar tissue shall be avoided. – Do not put the dispersive electrode pad over a patient's tattoo. – Do not put the dispersive electrode pad on the patient's skin over a metal prosthesis.

Dispersive electrode and placement which restricts blood flow shall be avoided. – All dispersive pads shall maintain uniform body contact. Potential problems include tenting, gaping and liquids interfering with adhesion. – Use pediatric electrosurgical ground pad according to weight limit. – The pad placement area shall be charted on the Intraoperative Nursing Record and Nurses' Notes.

Policy and Procedure  The Electrosurgical Active Electrode (Pencil): – Only electrosurgical active electrodes approved by the hospital Biomedical Engineer are to be used in the Surgical Services Department. – The active electrode shall be inspected at the field for damage before each use. – The active electrode shall fasten directly into a labeled, stress-resistant receptacle on the electrosurgical unit. – The active electrode cord shall be long enough and flexible enough to reach the operative site and the generator without stress. – The active electrode cord shall be free of loops, twists and metal clamps that can deviate current flow. – The active electrode and cord shall be inpervious to fluids. – The active electrode tip shall be secure and free of charred tissue. Use a moist sponge to clean the tip. – The active electrode will be placed in a holster at all times, when not in use.

Forms & Tools

Based upon the policy and procedure used at Stonewall Jackson Memorial Hospital in Lewis County, West Virginia.

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Pressure Ulcer Prevention Policy and Procedure

Forms & Tools

Pressure Ulcer Prevention Personnel: All accountable for patient care Patient outcomes: 1. Maintenance of intact skin in the patient who is at risk for breakdown. 2. Patient/caregivers verbalize knowledge of pressure ulcer risk factors, assessment, prevention and early treatment.

High Risk Diagnoses:

Factors That Contribute To Pressure Ulcer Development




Peripheral Vascular Disease Myocardial Infarction Stroke Multiple Trauma Musculoskeletal disorders/Fractures GI Bleed Spinal Cord Injury Paraplegia Neurological disorders (e.g., Guillain BarrĂŠ, multiple sclerosis) Those with unstable and/or chronic medical conditions (e.g., diabetes, renal disease, cancer) History of previous pressure ulcer Preterm neonates


Age greater than 75 Existing pressure ulcer Immobility Those having a procedure which immobilizes them for greater than one hour Bed linen Devices (e.g., oxygen tubing, splints, TEDs stockings) Sedation Sensory deficits Nutritional deficits/Weight loss Excessive exposure to moisture (e.g., incontinence, excessive perspiration, wound drainage) Those exposed to friction and shearing

Early and ongoing assessment of patients at risk for skin breakdown is essential. Prevention involves not only identification of patients at risk but also a detailed plan of interventions which address and minimize the effects of each risk factor.

Aligning practice with policy to improve patient care 81

Forms & Tools

Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis Asessement/evaluation

Interventions/key points

1. Identify patients at risk for developing a pressure ulcer upon admission and daily for at-risk patients or with any change in condition.

1. Determine an adult patient's risk for developing a pressure ulcer by using the Braden Risk Assessment. A patient is considered at risk if their Braden score is: 15-18 = Mild risk 13-14 = Moderate risk 10-12 = High risk 9 or below = Very high risk 2. Advance your patient to the next risk level in the presence of: A. Age over 75 B. Chronic illness C. Hemodynamic instability (e.g., diastolic blood pressure less than 60 mmHg). 3. Utilize the Nursing Care Plan to individualize specific prevention interventions. 4. Initiate Pressure Ulcer Treatment Protocol at the first sign of skin breakdown. 5. Consult WOC nurse when current plan of care does not meet the needs of the patient.

2. Assess specific vulnerable pressure points. A. Supine: occiput, sacrum, heels B. Sitting: ischial tuberosities, coccyx C. Side-lying position: trochanters D. Reddened areas which do not fade within 30 minutes E. Dusky or cyanotic areas F. Under devices (i.e., TEDs, pneumoboots, splints, collars, tubing)

2. Inspect the skin at least every 8 hours. A. Avoid vigorous massage over bony prominences. B. Patients with dark pigmentation will demonstrate a cyanotic area, warmth or complain of pain over the bony prominence.

3. Assess skin for exposure to moisture from intervals incontinence, wound drainage perspiration.

3. Cleanse and dry skin at routine intervals or and at the time of soiling, using a low residue soap. A. Initiate the Incontinence Protocol in the incontinent patient. B. Moisturize dry skin with lotion.

82 The OR Connection

Pressure Ulcer Prevention Policy and Procedure

Forms & Tools

Nursing Diagnosis 4. A. Assess mobility and activity status.

4. A. 1. Maintain or increase patient's level of activity, mobility and range of motion unless contraindicated. 2. Schedule regular and frequent turning and repositioning at least every 2 hours (e.g., alternating supine, left lateral and right lateral positions). 3. Individualize to the patient's needs based on risk and level of mobility. B. For sitting position in bed (head of bed greater than 30째), cardiac chair or wheelchair: 1. Assist/instruct patient to shift weight at least every 15 minutes. 2. Reposition at least every 30 minutes if patient cannot independently perform pressure relief exercises every 15 minutes. 3. Consult PT/OT for assistance in seating, positioning and wheelchair cushion options.

B. Identify sitting status.

5. Assess nutritional status.

5. Due to increased protein needs for healing, consult Nutrition Services for a nutritional assessment and plan at the earliest sign of skin breakdown.

6. Identify factors that increase shearing, friction and/or pressure. A. Shearing: Tissue layers sliding against each other; e.g., sliding down in bed. B. Friction: Skin rubbing against other surfaces; e.g., elbows and heels rubbing against sheets. C. Pressure/friction: e.g., heels resting on mattress, devices such as oxygen tubing, cervical collars, casts.

6. A. 1. Keep head of bed less than 30째 unless contraindicated. 2. Promote proper positioning, transferring and turning techniques. B. 1. Use reusable underpad, trapeze or lift sheet to lift, not drag, patient. 2. Utilize pillows or positioning devices to prevent skin surfaces from rubbing together. C. 1. The immobilized patient should have heels suspended off bed by using pillows or heel suspension boots. 2. Heel and elbow protectors are best used for reducing friction and should not be used for pressure reduction. 3. Pad devices when it is not contraindicated.

Aligning practice with policy to improve patient care 83

Forms & Tools

Pressure Ulcer Prevention Policy and Procedure

Nursing Diagnosis 7. Assess patient/family knowledge of pressure ulcer prevention, risk factors and early treatment.

7. A. Teach patient/family about the causes and risk factors for pressure ulcer development and ways to minimize risk. B. The patient or caregiver, or both, should understand the importance of the following: 1. Conduct regular inspection of skin over bony prominences. (Individuals can use a mirror if necessary to inspect their own skin.) 2. Follow appropriate skincare regimens. 3. Use measures to reduce friction/shearing. 4. Avoid vigorous massage of bony prominences or reddened area. 5. Include routine turning, repositioning and the use of pressure-reducing devices if patient is confined to bed and/or chair. 6. Avoid use of donut-type devices. 7. Maintain adequate nutrition and fluid intake and monitoring for weight loss, poor appetite or gastrointestinal changes that interfere with eating. 8. Program for bowel and bladder management. 9. Promptly report healthcare changes and nutritional problems to healthcare providers.

Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol. References Bryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000. Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11. Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal of Gerontological Nursing. 2004;30(11):46-51. Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania: Springhouse; 2001. Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers. Glenview, Ill; 2003. U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice guideline. 1992.

84 The OR Connection

Forms & Tools

Reprinted with permission.

86 The OR Connection

Policy Sample

Meets CDC 03’ and 05’ guidelines for environmental and TB infection controls

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Level-4 Gown

The liquid-proof Gore® membrane in our level-4 gown helps ensure maximum protection while keeping you comfortable.

To see a sample of this amazing surgical gown, please contact your Medline representative or call 1-800-MEDLINE.

©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Management/Employee Checklist

Forms & Tools

Checklist: Organizational Assessment Questions Regarding Management Commitment and Employee Involvement  Is there demonstrated organizational concern for employee emotional and physical safety and health as well as that of the patients?

 Is there tracking, trending, and regular reporting on violent incidents through the safety committee?

 Did front-line workers as well as management participate in developing the plan?

 Does the tracking and reporting capture all types of violence— fatalities, physical assaults, harassment, aggressive behavior, threats, verbal abuse, and sexual assaults?

 Is there a written workplace violence prevention program in your facility?

 Are front-line workers included as regular members and participants in the safety committee as well as violence tracking activities?

 Is there someone clearly responsible for the violence prevention program to ensure that all managers, supervisors, and employees understand their obligations?

 Does the tracking and reporting system use the latest categories of violence so data can be compared?

 Do those responsible have sufficient authority and resources to take all action necessary to ensure worker safety?  Does the violence prevention program address the kinds of violent incidents that are occurring in your facility?

 Does the program provide for post-assault medical treatment and psychological counseling for healthcare workers who experience or witness assaults or violence incidents?

 Is there a system to notify employees promptly about specific workplace security hazards or threats that are made? Are employees aware of this system?

 Is there a system for employees to inform management about workplace security hazards or threats without fear of reprisal? Are employees aware of this system?  Is there a system for employees to promptly report violent incidents, "near misses," threats, and verbal assaults without fear of reprisal?

 Have the high-risk locations or jobs with the greatest risk of violence as well as the processes and procedures that put employees at risk been identified?  Is there a root-cause analysis of the risk factors associated with individual violent incidents so that current response systems can be addressed and hazards can be eliminated and corrected?  Are employees consulted about what corrective actions need to be taken for single incidents or surveyed about violence concerns in general?

 Is there follow-up of employees involved in or witnessing violent incidents to assure that appropriate medical treatment and counseling have been provided?

 Has a process for reporting violent incidents within the facility to the police or requesting police assistance been established?

Source: U.S. Department of Labor. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Available at: Accessed June 19, 2008.

Aligning practice with policy to improve patient care 89

Forms & Tools

Incident Report

Confidential Incident Report To: ________________________________________ Date of Incident: _______________________________________ Location of Incident (Map/sketch on reverse side or attached): ______________________________________________


From: _______________________ Phone: _______________________ Time of Incident: ________________________ Nature of the Incident ("X" all applicable boxes):

❑ Assaults or Violent Acts: ____ Type "l"____ Type "2"____ Type "3"____ Other____ ❑ Preventative or Warning Report

❑ Bomb or Terrorist Type Threat ❑ Yes ❑ No

❑ Transportation Accident ❑ Contacts with Objects or Equipment

❑ Falls ❑ Exposures ❑ Fires or Explosions ❑ Other

Legal Counsel Advised of Incident? ❑ Yes ❑ No EAP Advised? ❑ Yes ❑ No Warning or Preventative Measures? ❑ Yes ❑ No

Number of Persons Affected: ___________________________________________ (For each person, complete a report; however, to the extent facts are duplicative, any person's report may incorporate another person's report.)

Name of Affected Person(s): __________________ Service Date: _____________ Position: ___________ Member of Labor Organization? ❑ Yes ❑

No Supervisor: __________________ Has Supervisor Been Notified? ❑ Yes ❑ No

Family: _____________________ Has Been Notified by: ? ❑ Yes ❑ No

Lost Work Time? ❑ Yes ❑ No Anticipated Return to Work: ____________________

Third parties or non-employee involvement (include contractor and lease employees, visitors, vendors, customers)? ❑ Yes ❑ No

Nature of the Incident Briefly describe: (1) event(s); (2) witnesses with addresses and status included; (3) location details; (4) equipment/weapon details; (5) weather; (6) other records of the incident (e.g., police report, recordings, videos); (7) the ability to observe and reliability of witnesses; (8) were the parties possibly impaired because of illness, injury, drugs or alcohol? (were tests taken to verify same?); (9) parties notified internally (employee relations, medical, legal, operations, etc.) and externally (police, fire, ambulance, EAP, family, etc.). Previous or Related Incidents of This Type? ❑ Yes ❑ No

Or by This Person? ❑ Yes ❑ No Preventative Steps? ❑ Yes ❑ No OSHA Log or Other OSHA Action Required? ❑ Yes ❑ No

Incident Response Team: ______________________________

Team Leader: __________________________________________ __________________ Signature Date

90 The OR Connection

Source: U.S. Department of Labor. Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers. Available at: http://www.osha. gov/Publications/OSHA3148/osh a3148.html. Accessed June 19, 2008.

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OR Connection Volume 3 Issue 2  

Medline's OR Connection Magazine, Volume 3, Issue 2 - FREE CE: Electrocautery Safety and OR Fire Prevention